HomeMy WebLinkAboutPermit ApplicationALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: 12017-0 Permit Number:
m 5
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: To Select from dropbox, click arrow at the end of line III
PROPOSED IMPROVEMENT LOCATION:
Address: I
Legal Description:
2 -
Property
Property Tax ID #:I 301 0I4 -1* -009 -10 Lot No.
Site Plan Name: Block No,
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION OF WORK:
LA4-6r Uunnox 3 �(�,l✓� seepL 5�lJ c unl�—
Wi-�h t0 Kul heat -
Wv HVAC LJ Gas Tank UGae
Electric Plumbing 0Spj
Total Sq. Ft of Construction:
Cost of Construction: $ 400.00
nn—u�c..K du L11dL aPPiy:
Piping n Shutters
ars LJ Generator
SFt. of First Floor: _
Utilities: Sewer ElSeptic
Windows/Doors
11 Roof
Building Height:
OWNER/LESSEE::
CONTRACTOR:
Name
Name: `
Address: �J512. -E {�f(,YCE? B�UG�.
Company:
Address:•5f�5r� N{Prl ik�
City:b/U(E PIErI� State_
Zip Code: Fax: Fax:
Phone No, Ma - S71 06-7
City: C�I71CiCQi State:
Zip Code: S 41 5 ! Fax:
Phone No.-"9--
o.- " 9 --Fill
E -Mail:
Fillin fee simple Title Holder on next page ( if different
from the Owner listed above)
E -Mail: �jeaL A_vn haQ. On (!'i
State or County Licen e: CA -C 181818 0
•• -�•�_ �• ��_•�••��••-•• •� .. mv.a, a nc.....nucu Nonce or,-ommencement is requnea.
SUPPLEMENTAL CONMUCTION LIEN LAW INFOR NnO[si_
Name:
_ f ppiieabh-
MMCAGE COMpANy. _ dot Appiitahie
Name:
Address:
S€'ATE€3FP A G1
Address
Cfw-
Lip: Phone
State: -
City State -
Lip: Phone:
EEE SMNPLE TME HOLDEEL
Name-
Not Appiicabie
Biz COMPAW Not Appikabie
Name-
Addrew,
Hameof plersorvikdting stliternent
Address:
City:
- Personally Kmmn OR Produced Identification
City:
Lip: Phone:
Produced
Zip Phone;
#' t- .R _�.x.. - Fe.a r_r -'n' •x- :.. sr.._.aF s et -.
structure.
In eration of the granting of this requested permit, I
tha
in accordance r t - . F.{^ Randa -: Ync : do hes aid Sc. reby -R s ;urity respects,
i` perform
The following building permit applications am exempt from undergoing a futt coricumencV review.
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Rev. SM17
Signature of Jowmer(L jConLactor /tgr t fix ne€
SkPature iaMwifractorIncense Hokle
STATEOFFLORI3A�j,.. n.n
COMM OF LA6
S€'ATE€3FP A G1
Ul. V
OF JI
The fo ng instrumentwas adaiowiedged he:ore me
The forgoing inswmenE was acknowledged ledged before me
this day of M" by
this, 'daytofs by
` • L[i� (e/
le,
y/ {!jam 20.70_
1A 1�}/V oma ,
Hameof plersorvikdting stliternent
Name ofperso t - sta f
Persorrally Known OR Produced ids-` . — fi a^
- Personally Kmmn OR Produced Identification
Type of Identification
Type of identification
Produced
Produced
////
C� && 7ZGJ.C-4&CQ
(Signature of Notary Ic State of norida )
{S x eof Nofa tic -state of
Commissi _ ruarsTlNE J. C(S }L
Coyprp- ,,,o, CHRISTINE J. CONWELL
- State of
,tiCpY P
�.•; Notary Public - State of Florida
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3+ • # GG 017839
Commission#GG 017839
e * R. Commission
Aug 21, 2020 -
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REVIEW REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
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Rev. SM17