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All APPLICABLE INq0 MUST EXC MPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: (cc I
_ 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:
PRPQSED I(UPR®UEI1/IENT L®CATION:
Address: 3 3 D11 W (zd�I
Legal Description: .
Property Tax ID#: 9q2C 701-- 0016 -.060 - q Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
IN 1
DETAILED DESCR=IPTI®N ®F U1/®RK:
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C�NSTRIJCTI®N IN,F®RMATI®N:
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: $ � i�� .�'y Utilities: —Sewer _.Septic' Building Height:
ODUN;ER/LESSEE-: C®N RASO "
11--
Name ..[+-P6 HC. Name: ` KL L hiPc
Address: (400 1�" r-PLL4 Company: bJ'i rtA V(
City: RIM L'w, State: Addres, 3014 12L,
Zip Code: Fax: City: 1!�% r �fff,g State:�'L
Phone No. `?�Z 334 - 30-00 Zip Code:3Af1 Fax: L&6—oib
E-Mail: Phone No. L(1
Fill in fee simple Title Holder on next page (if different E-Mail: !6Z°, or)/ , &W.,
from the Owner listed above) State or County License: '/ �1�]
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
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�S,IIPPLEM'ENTAD#CONSTR�UCTCO;N�LIE��VV INaFORMATION
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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 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/Agent/Lessee Signature of Contractor/License Holder
STATE OF FLORIDASTATE OF FLORIDA
COUNTY OF SALUte
COUNTY OF LUC,I
The f instru e t was acknowled a before me The f rgoing instru t was acknowledged before me
this c� y of i 20 by this day of E'_G 20rq)y
(Name of person acknowledging) (Name of person acknowledging)
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(Si �9}�blic-StaM (Signature of N ary Public-State of Florida")
Notary Public-State of Florida
Personally K o' 4 _ CMn¢odi�aeidAl�Z8�T1fi@ati n Personally K o r duced Identification
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Bonded t rough National Notary Assn. p.__ Notary Pub/
State �F
Commission No. (Sea Commission N' cFF`o My 0ommission#FF2 -'730Na
Bonded'th Expires
oum ,27.2015
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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.