HomeMy WebLinkAbout1604-0343 1' I
All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: l��lr 17Ja73
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Building Permit Application
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Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
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PERMIT APPLICATION FOR:
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PROPOSEDINfROEMEN , I®:CATION ���
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Address: bAJ
Legal Description:
Property Tax ID#: /3 Q/— A ff 11_1139V MLI Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:i
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Additional work to be pertormed under this per c ec aI that appy:
—Mechanical —Gas Tank —Gas Piping —Shutters IWindows/Doors
—Electric —Plumbing —Sprinklers —Generator Roof
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction:$ �� Utilities: —Sewer —Septic iBuilcling Height:
C1�11IER
Name Name:
Address: Company:
City: State-F74 Address:
Zip Code: Fax: City: State:
Phone No. (::7 7a � ��V Zip:Code: ". Y- Faz:
E-Mail: Phone No
Fill in fee
simple Title Holder on next page if different E-Mail .
from the Owner listed above) State or County License
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
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SSEJPPLE,MENTA1,C®NSTRIJ.CTlO'N LIEN 11U INFO'RMA7"fit)
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DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: _Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLE HOLDER: _ Not Applicable BONDING COMPANY: Not Applicable
Name: Name:
Address: Address:
City: City:
Zip: Phone: Zip: Phone:
OWNER/CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
I certify that no work or installation has commenced prior to the issuance of a permit.
St. Lucie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In consideration of the granting of this requested permit, I do hereby agree that I will, in all respects,perform the work
in accordance with the approved plans,the Florida Building Codes and St. Lucie County Amendments.
The following building permit applications are exempt from undergoing a full concurrency review: room additions,
accessory structures,swimming pools,fences,walls,signs,screen rooms and accessory uses to another non-residential use
WARNING TO OWNER:Your failure to Record a Notice of Commencement may result in your paying twice for
improvements to your property. A Notice of Commencement must be recorded and posted on the jobsite
before the first inspection. If you intend to obtain financing, consult with lender or an attorney before
commencing work or recording our Notice of Commencement.
Signature of Owner/Lessee/Contractor as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIQ4 STATE OF FLORIDA
COUNTY OF - COUNTY OF
The f oing instru ent was acknowledged before me The forgoing instrument was acknowledged before me
this day of 20 A by this day of 20_ by
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(Na ` f person acknowledging) (Name of person acknowledging)
(_,KignAure of Notary Public-St a of Florida) '\ (Signature of Notary Public-State of Florida)
Personally Known OR Produced IdentificatioPersonally Known OR Produced Identification
Type of Identification Type of Identification'
Prod ced - Produced
Commission No. eai Commission No. (Seal)
�� �ff% L SHA NA INGRAM
,a2o� `i��: Notary Public-State of Florida
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CO . TRs _ REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
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