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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: (D�
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Building Permit Application
Planning and Development Services I'
Building and Code Regulation Division l
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
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PERMIT APPLICATION FOR: '!
PR®'P®SD INPRDU'EMr, ENT LOCATION:
Address: Q;
Legal Description: -1 0 Pk_i�"'LA U P IV 2' iD A `1' OT- 92
Property Tax ID#: /413Z ' 0—K C-0C'2 6 '2 " D 00 -3 Lot No.
Site Plan Name: Block No.
Project Name: ill
Setbacks Front Back: Right Side: Left Side:
DETAILED DE�SGRiIP 10N OF 1N�'R�K.
E&z e r zi w-c_ne c R7e-
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N®NSTRl1'CT Q' I 'F® ION:
Additional work to be pertormed under this permit-check all that appy: 1`f
_Mechanical _Gas Tank _Gas Piping _Shutters Windows/Doors
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Electric _Plumbing _Sprinklers _Generator j Roof
Total Sq. Ft of Construction: Sq. Ft.of First Floor: H
Cost of Construction:$ _;;00'C)C�' Utilities: —Sewer —Septic �' Building Height:
01N'NER/LE�S�SEE: �ONTRACTO
Name jL1�►el 't �- Lu ,'!S 0t--1 Name: 1Ii ,Qin, z�fi
hl
Address:
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Address: (Zoo /J 37'7-l-t -S'7 Company: E. `gam-„r lir- ELI= c- e-1 c
City: State: Address: /6,401,
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Zip Code: '%`'I 9 L-4L 'l Fax: City: POZ+ S f L�c r•e State: �L
Phone No. Zip Code: 311 l6i5-3 lil Fax:
E-Mail: Phone No '�i ?,H
Fill in fee simple Title Holder on.next page (if different E-Mail IL"u/- Cnyl,+V-)-o L-r
from the Owner listed above) State or County License i F R--A 3!0 Z Ll 5'7'7
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required. !�
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SUPNOR; A CO'NSl`RTURNM .N=10110W I " F®RNIATI(J'N;
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY.[ _Not Applicable
Name: Name:
Address: Address: f
City: State: City: I Iti State:
Zip: Phone Zip: Phone: 1
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FEE SIMPLE TITLE HOLDER: _Not Applicable BONDING COMPANY: 1 Not Applicable
Name: Name: Jll
Address: Address: ! II
City: City:
Zip: Phone: Zip: hone: 1'
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.
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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,ih all respects, perform the work
in accordance with the approved plans,the Florida Building Codes and St. Lucie County Amendmients.
The following building permit applications are exempt from undergoing a full concurrency reviewl: room additions,
accessory structures,swimming pools,fences,walls,signs,screen rooms and accessory fuses 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,'Iender br an attorney before
commencing work qr recording our Notice of Commencement. it
Signalrure of Owner/ essee/Contractor as Agent for Owner tgnature of Contrail for/Licenise Holder
STATE OF FLORIDA STATE OF FLORIDA IN
COUNTY OFA, COUNTY OF ` 1 V
The forgoing instrument was acknowledged before me The forgoing instrument wasi'I cknowledged before me
this day of 20\ by this�day of ;'l 20 1% by
(Name of person acknowledging) (Name of person acknowledging)
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Signature of Notary Public-State of Florida) (Signature of Notary Pu is-itate of Florida )
\ Personally Known 1 OR Produced Identification
Personally Known OR Produced dent'ficaYo „
Type of Identification A Type of Identification I I
Yp ���� LASHAHNA ItJGRAM Yp
Produced .'SP"y A'''
�,. Public-State of Florida, Produced ';I """'• LASHAHNA INGRAM
My Comm:Expires Dec 20,2018 it°* tr` Notary Public-State of Florida.
Commission No. i"�' o`c� Co > )on#.FF 177249 . Commission No. 4s• .•_My�SMOExpires Dec 20,201
� CF.+, Bonded through National IN
Assn. ;9r Commission#FF 177249
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