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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: 1�4 ' co
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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:
PROPQSED INRROVEMENT1OCATIC3;N"
Address: ZKC 11:11 'y1
Legal Description:
Property Tax ID#: ,,q19 -"- D OM-c �� l'1 Lot No.
Site Plan Name: ! Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION OF WORKS ,r �� 1f "
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C'OfV51"RUCTIONINFORMATIOIV
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Additionalworkto a per orme under this permit-check�a that apply:
_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:
OUV►NER/LESSEE ' 3 t = ' CONTRA
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Name Gv� ame: " (Jt ex
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Company:
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City: State:_ Address:
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Zip Code: Fax: City: lS'L j� I' Stater
Phone No. 77` -r�_W- D Zip Code: Fax:
E-Mail: Phone No 2 2e---7 ^ ZF-d 96,1
Fill in fee simple Title Holder on next page(if different E-Mail
from the Owner listed above) State or County License
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
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SU`nPPLEM NTAL�CONSTRl1rCTIg NLIEN yWINOR(1/IAgTIQN
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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 i pection. If you intend to obtain financing, cons It with len r or an attorney before
commAncinj w r or recording our Notice of Commencement.
I Y
Sig a e of Owner/Lessee/Contractor as Agent for OwnerSign re of Contractor/License Holder
i
ATE OF FLORIDA S TE OF FLORIDA
COUNTY OF "S� COUNTY OF
The for oing instrVrfient was acknowledged before me The forgoing instrument was acknowledged before me
this day of 20L by this day of 20_ by
ln
i o�A ,.Jo.nrn�
(Name of person acknowledging) (Name of person acknowledging)
J(Sia4�_eof Notary Public- ate of Florida) (S ure of Notary Public-Sta of Florida )
Personally Know�j OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced � Produced � '
LASHAHNA INGRAM PR.,,,�e, LASHAHNA INGRAM a
Notary Public-State of Florida, Public-State of Florida_
Commission No.• _. ' °• My Cjhxpires Dec 20,2018 Commission No. ° ' ; My C xpires Dec 20,2018
Commission#FF 177249 * o�=
Commission#FF 177249
nnded thrnph National Notary Ass
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE., MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 7/2014