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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED 11 �-�p
Date: Permit Number: 4�� ' OL'z'
Nib 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
PERMIT APPLICATION FOR:
'P.ROPOSED IN'PROUEMENT.LOCATION
Address: 02 e!_ez •3 9j(
Legal Description:
Property Tax ID#: Qqo '50 1 Lot No.
Site Plan Name: Block No.
Project Name: J10, Co Yn M QLAt( 4 U1 JAS YID 2.1,X4 5011e Al aO
Setbacks Front Back: Right Side: Left Side:
77777777777777
DETAILED DESCRIPTION OF WORK: ������` �� b'� '
AT
t
COfNSTR,UCIN
TtQN ,ORMATION
Additionalwork to_ e performed under t E permit-check all that appy:
_Mechanical _Gas Tank _Gas Piping _Shutters _Windows/Doors
Electric _Plumbing _Sprinklers _Generator _Roof
Total Sq. Ft of Construction: �1 Sq. Ft.of First Floor:
Cost of Construction:$ ��'O� Utilities: —Sewer _Septic Building Height:
OWNER%LESSEE CONTRACTOR
Name l i/L 1� 5 yYle�t ' yf�lame: ^• /& .
Address: 3/ /o'L ig UE S Company: L? f!
City: F—oy-t e.-dw- State: F1 Address: 13 (,i--16-A @e S.�
Zip Code: .3 SD Fax: City: rYl cC�e/? State:
Phone No. Zip Code: H,-3-3 36 Fax:
E-Mail: Phone No - 75 3- 65 2 7
Fill in fee simple Title Holder on next page(if different E-Mail � a ' c4
from the Owner listed above) State or County License
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INfORIVIATIC�N
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: _Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLEHOLDER: _Not Applica le BONDING COMPANY: Not Applicable
Name• - Ce rY1 Name:
Address: G 3 Address:
City: o ►--cL' 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.
Signature of Owner/Lessee/Contractor as Ag r Signature of Contractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF COUNTY OF -1.,,,� Q
The forgoing instrLoen was acknowledged before me The fing instrument was acknowledged before me
this day of 20 ( by thisday of 201V.by
(Name of person acknowledging) (Name of person acknowledging)
ignature of Notary Public- tate of Florida) (Signature of�NotaryPubritate of Florida)
Personally Known OR Produced IdentificationPersonally Known OR Produced Identification
Type of Identification Type of Identification
Produced Produced
iL.%�-iX420 r a- O-i� °i�•O
Commission No. (Seal) Commission No. (Seal)
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
ev.