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PPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTEDte: Permit Number:
i
Building Permit Application
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 r
PERMIT APPLICATION FOR:
PREPOD ( O1YMENT LaCATIN: a='%
Address: S
Legal Description: — ZOL� /.1/ �' v'/ee
Property Tax ID#: � • X51 �' l� `�' ��� Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
77777
DAA O D SCI, QWORK _
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Additional workto a pertormed under this 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:$ /n� Utilities: _Sewer _Septic Building Height:
01�1/NERjLSSEr 4
CONT
Name > D Name: J49A1 INs
Address: �� ��� ���� Company: -r/
City: « � State:_ Address: aT=;?-
Zip Code: Fax: City: I� Stater
Phone No. Zip Code: 3''19 Fax:
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 OOJ�3 �
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
DESIGNER/ENGINEER: Nat 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: -Nat 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 i en to obtain financing, consult with lender or an atto efore
commencingwork or recordingur N tice of Commencement.
Signature of Owner/Lessee/Contractor as Agent for Owner Signature of Contractor/Li ense Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF COUNTY OF :x,��.
The forgoing instr e t was acknowledged before me The fring instr ent was acknowledged before me
this day of 20� by thisday of 110.. _
(Name of person acknowledging) (Name of person acknowledging)
� 1
(Si ature of Notary Public- to of Florida) (Signature of Notary Publi to of Florida)
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced _ i Produced
-. 3 .:�
Commission No. (SM$AHNA INGRAM Commission No. (Seal)
4M;, Notary Public State of Florida Notary, „oiic -State of Florid
-Mv Comm.Expires Dec 20,2018
es Dec 20 2018
Commission#FF 177 ;r,T Po�c Commis ion#FF 177249
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COMPLETED
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