HomeMy WebLinkAboutOwner Builder Affidavit (3) it I i
All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED i.
Date: Permit Number:',, X0 (000(a
Building Permit Application
Planning-and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982 i
,Phone: (772)462-1553 Fax: (772)462-1578 Commercial ResidI ential
I
PERMIT APPLICATION FOR:
PR0P'O ED INRROVEMENT LOCATION „
EC AL Zs/_�s cy
L2 .
Address: SCL•
i
Legal Description: 1611 h k DR r Ve�— WA-X AI
PropertyTax ID#: �34 —6 0'`04 - 0007 Lot No.f7' `^3
Site Plan Name: Block No.
I
Project Name: 0kz"Af9 br2-
Setbacks Front �' Back: Right Side: Left Side:
DE1'AtLt3 DESCRIPTt(?N £�F 1NPRK s
CQIUSTRI.)CTION INFORMATION Irk
e � '
itiona wor to be performed under this permit—check all that appy:
—Mechanical —Gas Tank —Gas Piping —Shutters _! Windows/Doors
i —Electric —Plumbing —Sprinklers —Generator _Roof Pitch
I ' I
II tal Sq. Ft of Construction: � Q Sq. Ft.of First Floor:
Cost of Construction: sk ��� oD Utilities: Sewer Septic Bullding``Height:
-
Name 6 N F Name:
Address:_? �P�jL 15LLS EXUpe Company:
city: �.� /P� A LState: L Address:
Zip Code: Fax: City: State:
,Phone No. ly'a7i Gi��,� g 9 Zip Code: Fax:
� 1 I
E-Mail: fO Phone No
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.
i ,