HomeMy WebLinkAboutBuilding Permit Application All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO�BEE^ACCCEPTTEDD ) /�L_� /� /
Date: n Rd Gia;<I:-•-Et�G�k�''r r: I (�V U' 0Zo l0
—MAY 13 2016 RECEIVox� �
s PERP01TT1NG � y12016
• St. Lucio 0
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Building PerNfAr ocation
Planning and Development Services ,t. Lucie County, FL
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 Commercial �i _ Residential
PERMIT APPLICATION FOR: <-aoRM e
figRQPOSED IN'RR®1lEMiENT LOCATION:
Address: e32/5 Z&I-evr-e w `f 161 -e"C'
Legal Description:
Property Tax ID#: VD ' Lot No.
Site Plan Name: j/ Block No.
Project Name: 9-,eri ce—c-
Setbacks Front Back: Right Side: Left Side:
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DETAILED DE=S+CRI�PTION C�}'F 1INO,R+Kz:
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C®NSTR'11CT1ON LN�F®�RMI�►TI®N:
Additi obepertormed un er t is permit–check all that appy:
_Mechanical _Gas Tank —Gas Piping _Shutters _Windows/Doors
Electric _Plumbing _Sprinklers _Generator _Roof
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: $ 2 y Utilities: —Sewer _Septic Building Height:
OUti/�NERjLESS'EE: ' s TC
NName au� �' ortrc, 49x/ me:Address: /`/7Z! 15 (-- (,c,�s 49Zmpany: 444/.-G
City: -5V1 0 v.,f ;Cc- State:_ Address:
Zip Code: 3XfJ77 Fax: City: State:f�L
Phone No.. Zip Code:�'19Fax:
E-Mail: Phone No
2 6-
Fill
Fill in fee simple Title Holder on next page (if different E-Mail
from the Owner listed above) State or County License C c—' <
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
SU`PPLEMENTAI C®NSTRIlCTION LIEN LAUU IN'FOR1MATl0N:
DESIGNER/ENGINEER: of 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 thepermit 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 FLORIDA/�� STATE OF FLORIDA
COUNTY OF `�.u 0,1E COUNTY OF 4,
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this II day of M>aU 20-$ by this I I day of -PAig 20 by
A ki:� 7�a _U.U,
(Name of person acknowledging) (Name of person acknowledging
its,--�
(Signature of Notary ublic-State of Florida) (Signature of Notary Public-State of Florida)
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of ldenVd4eation Type of Identif' ion
Produced _. 1r.duced
KAREN S. NIELSE I .
B�C ....ibm'F't:.-a':iv:.T.Y.r�vT.Kg+a.!yi
Commission No. mission# FF 115627CC mission No. 11 1!1, iiI;ia NIELSEN
oa My Commission Expire
Commission# FF 11
June 12, 2018 *= 5637
- -
amno �yr. o�,r My Commission Expires
une 12, 2018
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