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PLANNING & DEVELOPMENT
BOARD OF SERVICES DEPARTMENT
COUNTYCOUNTY
COMMISSIONERS . � Building & Code
Regulation Division
ELECTRICAL SERVICE CHANGE AFFIDAVIT
Building Permit Number: — 016t
Job Address: e z A-r
Electrical Contractor Company: 4AA1 A — -:Mr
Qualifier: S jlpl.W Wgh h
County License#: Qkz7 State License#: 0
1, 3 Sh,6u..)n LAJeb�2 DO HEREBY AFFIRM:
Print Qualifier Name
That I take.full responsibility for the electrical work performed under the above permit. I also affirm that I have read and understand the enclosed
cover sheet,"ELECTRICAL SERVICE CHANGE PROCEDURES FOR ELECTRICAL CONTRACTORS"and agree to fully abide by them. All work
will be performed to the requirements of the NATIONAL ELECTRICAL CODE 2008 and the FLORIDA BUILDING CODE(latest addition).
I further understand that:
This procedure is a Privilege being granted to licensed Electrical Contractors only and may be revoked by the Authority Having
Jurisdiction at any time for just cause.
By signing this affidavit the Electrical Contractor is taking full responsibility for the work performed.
IF ANY UNSAFE OR POTENTIALLY LIFE THREATENING DEFICIENCIES ARE FOUND AT INSPECTION,THE INSPECTOR WILL
NOTIFY THE UTILITY FOR IMMEDIATE DISCONNECTION AND YOUR PRIVILEGES WILL BE REVOKED.
Qua' re Date
Sworn to and subscribed before me this day of 20j2
Seal/Stamp
By
•Notary Public,State of Florida
Personally known to me Produces identification
JASON M RAULERSON
NOWY VWIC•8410 of Florida
l CON01100 I FF/65546
MY Contin.EWM Feb 28,2020
kDOVSKY,District No.I•TOD MOWERY,District No.2•PAULA A.LEWIS,District No.3•FRANNIE HUTCHINSON,District No.4•CHRIS CRAFT,District No.5
County Administrator—Faye W.Outlaw,MPA Website:www.stlucieco.taov
2300 Virginia Avenue•Fort Pierce,FL. 34982-5652
PERMITTING AND ZONING:Phone(772)462-1553 FAX(772)462-1735
CONTRACTOR LICENSING:(772)462-1672•CODE ENFORCEMENT:(772)462-1571 .INSPECTIONS:(772)462-2165
FAX:(772)462-1148