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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED 1
Date: 1 lam_ Permit Number:. 0
I
RECEIVE'
BUilding Permit Application
MAY 12 2CES
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)1462-1553 Fax: (772)462-1578 Commercial Residential
PERMIT APPLICATION FOR: � � 9e�Y
PROPOSED I'N°FROU�,EMENT LFOCA10<N;.,
Address:10 I{o5ot 0C F � 1 � � �
Legal Descriptia& L,on: tlB e \ 133 L6+ 1q(A01
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Property Tax ID#:w) �i n [`> ^ 3 5c., - 000 - (0 Lot No.
Site Plan Name: Block No.
roject Name:! Q k, W DO a-1 k
Setbacks Frlont Back: Right Side: Left Side: 021y '
DET FLED D:E�S'CR�I`PTION O.F 'V1/0 . K
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C' NSTR;UCTIO , IN�F®R�: �4TLON ,
ditional work to b_e_p_e_ff6_rmed under tis permit-c ec all that app y:
_Mecha ical _Gas Tank —Gas Piping _Shutters _Windows/Doors
Electric _Plumbing _Sprinklers _Generator _Roof
Total Sq. Ft of Construction: CA �6 Sq. Ft. of First Floor:
Cost of Construction: $ Utilities: —S.ewer _Septic Building Height:
0 N'ER/LE�S�S'E' : ' �CONTRAC OR.
Name* e Fv--c Name:
Address:*(- r-to J"U AAV,' Company:
City: State-1cAddress:
Zip Code - S Fax: City: State:
Phone No. 7 1 At to L- Yqlo q Zip Code: Fax:
E-Mail:.' C 7 50Phone No
= i
Fill in fee simple Title holder on next page (if different E-Mail
from the Owner listed above) State or County License
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If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
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SL1P'PLEMENTAL C®NSTRIUCTI®N LEEN LAW INF®RMATI "
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: _ Not Applicable
Name: � �' r �'I_ )0, Name:
Address:-'W'71 42Address:
City: Uer - State:&1or,1do City: State:
Zip: nff 0 z I O Phone ,�, 7 33 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.
S'gwpur :o : w,rµ/Lessee/Contractor as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA - M:xR8
STATE OF FLORIDA
5
COUNTY OF COUNTY OF
The forgoing instrument was acknowledged beThe forgoing instrument was acknowledged before me
this day of 20� b this day of 20by
V =15t
J'e F- 8 'Py"
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(Name of person a knowledging) �T= (Name of person acknowledging)
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(Signature of Not6ly Public-State of Flori a) (Signature of Notary Public-State of Florida)
Perso a ly Known OR Produced Identification Personally Known OR Produced Identification
Type
f Id ifi ation Type of Identification
Produced Produced
Commis ' n No. (Seal) Commission No. (Seal)
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.