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ALL APPLICABLE INFO M T E COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: l Permit Number:
• I
e
Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982 t4
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
PERMIT APPLICATION FOR: To Select from dropbox, click arrow at the end of line
PROPOSED IMPROVEMENT-LOCATION:
Address: ' 'Rv& CCC C 6 l' ( P _'�
LegalDescription:_ (� e Ue 1 1 -a
Property Tax ID#: — Da(o —® Lot No.�
Site Plan Name: Block No. 1
Project Name: Q�
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION`OF WORK.'' /.
�l�. PI (-k"\ rood
I sq���res CsV\ C\
CONSTROCTION-INFORMATION: _
Additional work toe performed under this permit–c ec a appy:
E1HVAC Gas Tank Gas Piping _Shutters Q Windows/Doors
Electric El Plumbing Sprinklers E Generator _ oof
Total Sq. Ft of Construction: con S . Ft. of First Floor:
Cost of Construction:$ ® - (� Utilities: Sewer E]Septic Building Height:
OWNER/LESSEE: ` 'CONTRACTOR:
Name 014 Name:
Address: 2t, Company: T,s e
City: State: Address: .�
Zip Code: Fax: City: State:
Phone No. Co 9'� Zip Code: C,�J� Fax:
E-Mail: Phone No.
Fill in fee simple Title Holder on next page(if different E-Mail: qr
from the Owner listed above) /krState or County License:
If value of construction is$2500 or more,a RECORDED Notice of Commencement is required.
9
.,SUPPLEMENTAL CONSTRUCTION.LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: _Not Applicable
Name: Name:
Address: i 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:
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
ignat e o 0 er/Lessee/Age Signature of Contract License Holder
STATE OF FLORI 1 STATE OF FLORIDA
COUNTY OF COUNTY OF `
The forgoing instrument was acknowledge�tby
fore me The for o instrument was acknowledge efore me
this- ay of --�C�AILL= 20 this-b of 20 �� by
(Name of person acknowledgi (Name of person acknowledging)
C
ig ture f Notary Publicblic-S eS a of Florida) (Signa re of otary Public- tat of Florida)
PersonallyKnown �� OR Produced Idehtification Personall Known OR
Y Produced Identification
Type of Identification Produced Type of Identification Produced
Commission No. 000,5�7NOto�dfic state of Florida Commiss n j to of Florii�{eSeaSte - �r•a Frederick Stephen P Frederick My C:.,!iioiasion EE 868848 My Commission EE 868848
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Revised 07/15/2014
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