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ALL APPLICAAB/ INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: / 1 Permit Number:
Building Permit Application
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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: To Select from dropbox, click arrow at the end of line
PRQPOSED,IMPROVEMENT LOCATION. }} n
Address: ._G L— q9
Legal Description: Gf frRv` V tw—
Property Tax ID#: � I" a TV— `���'1 `,�0L/ Lot No.
Site Plan Name:{ Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION'OF`WORK:.'
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CONSTRUCTION INFORMATION
Additional work toe e orme under this permit—check a appy:
❑HVAC 11 Gas Tank Gas Piping _Shutters Windows Doors
❑Electric ❑ Plumbing ❑Sprinklers ❑Generator ❑ Roof Roof pitch-
Total Sq. Ft of Construction: S Ft.of First Floor:
Cost of Construction:$ 000 .00 Utilities:Sewer❑Septic Building Height:
OWNER/LESSEE. .CONTRACTOR: -'
Name `U Name:
Address my U Company:r'
City: �� �E State Address: �J [,P
Zip Code: Fax: City: Rj_ State--
Phone
tate-Phone N _4Q — Zip Code: 3M55 Fax:
E-Mail: U Phone No J-00— 0_5
Fill in fee simple Title Holder on next page(if different E-Mail: OLi I cafn
from the Owner listed above) State or County License: G l
If value of construction is$2500 or more,a RECORDED Notice of Commencement is required.
4 .
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 i end to,obtain financing, consult with lender or an attorney before ,
commencingwo r reco in our N is ' of Commencement.
,Sign re of O ner/Lessee/ ntractor as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA /�r,�p i ' ��JC� STATE OF FLORIDA i
COUNTY OF 1 rt(Cl� COUNTY OFI ti
The forgoing instrument was acknowledge before me Thergoing instrument was acknowledged before me
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this c30 day of.�� ,20by this Uday of ,20L-(p by
(Name of erson ckhowledging) (Name of person acknowledging)
i
ota ubli ate of Florida) (Signatur Public- ate ) W
oto . � ---- (� ���a�'MacR �
sonally Known OR Produgdt& n Personally Known_�-.GR Produce m I ow
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on
o entification .�\ �i°P�l,�'��,, S�Oty�ti+tiS�14'�INC, Q ype o entification � 'ii���% ��
," ' `'�, , ti, tit '�n2 Produced =2: __ ExP�tes'. ��otaN
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Commission No. � •• Seal) Commission No. �'� „�.����` (Seal)
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REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
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