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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: a3 `� Permit Number: IroOA-dpi 4 3
RECEIti''D AUG 2 3 2016
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 t�
PERMIT APPLICATION FOR:
P O.POSED IN'P-,P, @YEME¢NT LOCATION:
Address: - & )
Legal Description: I V
Property Tax ID#: -3 2 '53 L 0007 0(2'J- '- Lot No. 3 3
Site Plan Name: Block No. 'Z-
Project
Project Name:
Setbacks Front Back: Right Side: Left Side-
3",
ide:3F 1GI/ORK: .
CONSTR.UCTIO`N NFOR
WORMEms im
Additionalworkto a performed under this permit-check a 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:$ Utilities:' —Sewer _Septic Building Height:
oeOWNER/gESkSEE•� � ;� , j��� � CONT�R�AC1'OR: _
Name rd-4A Name: i
Address- Z _ Company: �C
City: S is State:t"- Address: A-/
Zip Code: ZFax: [[�� City: !r L State
Phone No. Z 2 _ '7 Zip Code: Fax:
E-Mail: C Phone No -ell&P-- 006
Fill in fee simple Title Holder on next page (if different E-Mail ,v MS,✓ ° co 4,1
from the Owner listed above) State County License
If value of construction'is 2500 or more,a RECORDED Notice of Co encement is required. 5�
i
SUPfPLEME�NT�AL CONSTR'UCl'ION� LUE�N' LAW IN!F�q RMATION.:
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: lot Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLE HOLDER: Not Applicable BONDING COMPANY: ('Q_Not Applicable
Name: Name: I�
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 reording your Notice of Commencement.
X1
S' n e o w er/ / tract for Owner Signature of Contractor/License
STATE OF FLORI A STATE OF FLORIDA
COUNTY( ���'� COUNTY OF_,5J 1,4alt-
The fq%oi_ng instrumen was acknowledggd iefore me The forgoing instrumAnt was acl owledged before me
this day of 20 (goy this day of 20/&& by
017 1
( of person acknowledging) =ofrson acknowledging)
V
(Signature of Not6ty Public-State of Florida) (S n ture of Not yPublic-State qTlorida)
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of I Type of Identification
Produce ' Produced t LV e
19,
BERLY R.HILLER
FNota Public,State of Florida
_ Notary Public-State ot�� �tpG{�pn#GG 9650
Commi ib Com Commission No.
#FF 23 730 res Juy 16,2020
9;Foc«o? MY Comm.Expires May 27,2019 My comm.expl
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REVIEWS FRONT ZONING UPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
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