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All APPLICABLE FO MUS BE COMPLETED FOR APPLICATION TO BE ACCEPTED I R
Date: ` Permit Number: I� ` _0OD /
s
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:
PROPQS // ANT LOCATION:
Address: , all�� lot(n e(d0C a
Legal Description: Cf0 2_L, (0 0 3 mod* N
Property Tax ID#: Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
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Additional work to be performed 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:$ 2,1A Utilities: —Sewer —Septic Building Height:
Q1N3N�ER/LE�S�SEE` /v C� Nl' ;CYTO' I•
Name K LLAI;611,�CrillAddress: V a`Gc �Y���y,,� fte:
pany:
City: State:_ Address: Geo'
Zip Code: Fax: City: Uci-e State: —(_
Phone No. 60:7_ z 5�0 Zip Code: Fax:
E-Mail: Phone No
Fill in fee simple Title Holder on next page (if different E-Mail
from the Owner listed above) State or County License & ✓L Z
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMEMS TAL CONSTRUCTt®N LtE LAW INF®.RMAT(ON:
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 thepermit 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 'ns a io If you intend to obtain financing, con uIt with I r or an attorney before
comme in r r ec .rdi our Notice of Commencemen . /
Signature of Owner/Less a/Cont ct r Agent for Owner Sign Lure Contractor/LiH Ider
STATE OF FLORIDA I STATE OF FLORIDA
COUNTY OF ���� , COUNTY OF
The forgoing instru ent was acknowledged before me The d fo Nay
instrum 't was acknowledg efore me
thisa day of eC, 201G by this day of 20� by
(Name of person acknowledging) (Name of person acknowledging)
(Signature ofd ' K Public-9=eL41f6F1¢W0a (Signature of Notar ublic-State of Florida)
Notary Public-State of Florida
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Personally Knb Coprgiggi� Q� ifi tion Personally Known .o ,ProduceOv FF
Type of Ident f�ca y XMV Ex ires May 27,2019 Type of Identificatioe•. ';_ ary Public-State of Florida
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Commission No. (Seal) Commission No. gl)Not
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REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.