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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
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Date: Permit Number: 'J
Building Permit Application
Planning and Development Services I
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce A 34982 11
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
PERMIT APPLICATION FOR: I� TC E+�A-E:
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Address: R)CL1_,w1rA M , a r�
Legal Description: Lin% If) ' L' 55 �b
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Property Tax ID#: X0 (_06 '5—a3-1.3 •--ca:) i Lot No.
Site Plan Name: ili Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side: .'1
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kCON TRUCTIONINF_ORMATION
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Additional work to be 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: $ 00-• Utilities: —Sewer —Septic Building Height:
�QW.�N'ER%L�'ESSE�' y�� '� ��,rCO}NTRAGT',OR•
Name - Name:
Address: 0,*--) 1 �(.� • Company:.
City:�-� . ��Q�cr° State:RI
"Address:
Zip Code: � �', � Fax: City: i State:
Phone No. 99 SLI L,R 55 Zip Code: Fax:
E-Mail: Y e C6 Phone No
Fill in simple Title'Holder on next age (if different E-Mail
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from the Owner listed above) State or County License
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if value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
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SUPPLEMEN0004,10 ASTIRENST FO'RMATI'®N:
DESIGNER/ENGINEER: _ Not 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 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.
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S nature of Owner/Lessee/Co tractor as Agent for Owner Signature of Contractor/License Holder
TATE OF FLORIDA STATE OF FLORIDA
COUNTY OFCOUNTY OF
The forgoing ins ment wa acknowledged before me The forgoing instrument was acknowledged before me
this day of 20J by this day of 20_ by
(Name o person acknowledging) (Name of person acknowledging)
(Signature of Notary Public-St to of Florida) (Signature of Notary Public-State of Florida)
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced Produced
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Commission No. 1 „ e@ HAHNA INGRAM ommission No. (Seal)
pR UB”
Notary Public-State of Florid
COMITission# FF 177249
REVIEWS FRONT I116dedth AWfiRaV60As n. LANS VEGETATION SEATURTLE MANGROVE
COUNT- rRCV - EVIEW REVIEW REVIEW REVIEW
DATE -
RECEIVED
DATE
COMPLETED
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