HomeMy WebLinkAboutSpecialty Permit Applicationq09 G
FDate: Fee Due: e;9_ Receipt# Permit #
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Planning & Development Services y p
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
❑ Electrical
❑ Plumbing
❑ RVAC
LISFence
❑ Shed
❑ Demolition
❑ Gas
❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
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1. Location/Site Address: Ave. 3 if. 1216reGt rL-q qI3p hh,
2. Parcel ID Number: (1}aq- - o -tom-(o I4� 50l`(2u4E, - W IV
Office Use
Section
Township
Range
Map Page
Zoning
land Use
Initials
Only
3. Complete Description of Project or Work:
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4. Owners Information 5. Contractors Information
Name: �17G`(I, r14y
Address: `a�(� V { VQI rl ld, Rve -
FL Reg/Cert #:
County Cert#: 209
City: I'i-. Pi erne- State: F- Business Name: ilr1'1p-n 1
Zip: 341iiKa Phone: /{(te2-I�7Phone: Fax:yS-'3b'3S
6. Value of Construction: $ 115' ..xx J
OWNER'S AFFIDAVIT: I certify that all of the information contained in this application,I-s correct and that all work will be done in
compliance With all applicable laws regulating cons motion If zoning.
Ches{-ev- R(chvnuy)
PRINT OWNER OR CONTRACTOR NAME SIGNATLW,1?i-0WTqVk OR C N A OR
STATE OF FLORIDA, COUNTY OF ma'r+i rl
ACKNOWLEDGED BEFORE ME THIS 1344'1 DAYOF ZN1• ,20 BY CX1eS+e4- eiCkMOI-d
WHO IS PERSONALLY KNOWN TOME V OR WHO HAS PRODUCED _
NOTARY PUBLIC -STATE OF FLORIDA
AS IDENTIFICATION. yf ^ , ��•,, Deborah V Nance
Com[ni$si #DD980801
SIGNATURE OF NOTARY TYPE OR PRINT NAME OF NOTARY 5j' �'••' Expires. PR.12, 2014
COMMISSION NUMBER DMO,09,0) BOND®TfBitiAN+.\7[CBOS'nINC CO., INC.
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
EXEMPT: A/C -HEAT REPLACEMENT WITH CONTRACT UNDER $7500.00
Revised 04/26/2010