HomeMy WebLinkAboutSpecialty Permit Application1 •Date: j 3 Fee Due: 5 , a, Recei t# 6t5j1 Permit # 310 -d0
r��lj.
COUNTY
F I. 0 R I D A ^-
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
❑ Electrical l�Plumbing ❑ HVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
See page 2 for instructions and additional paperwork required for specialty permits
1. Location/SiteAddress: � AV011 ��• �dr'� 5�.�.InC��.��. J� ���
2. Parcel ID Number: 3491-5S®-O( It-000-5
Office Use
Office Use
Only
Se�Township
Section
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of #roject or Work: �p�\\ate ter Vdn R,,0-' i i. wpyhr, 1•Qp►'ttt--I r,
4. Owners Inform"a�tion 10u , C .WLc v► n 0,5 5. Contractors Information
Name: �c1�v� `Jm`C.1'1.1nY10�s.
Address: VAM3
City: '-, State: 7-
Zip: Phone:
6. Value of Construction: $ 3 al()
FL Reg/Cert #: c�C`4-0)-►�zo
County Cert#: 2315
Business Name: an.u1 F�a����nnr,,In
Phone:jlL�l-QM06 Fax:-��- 11�GJl
OWNER'S AFFIDAVIT: I certify that all of the information conta' ' this p
compliance with all applicable laws regula in I
�
P OWNER OR CONTRACTOR NAMME/ SIG ATURE OV
STATE OF FLORIDA, COUNTY OF S' • L L o e ��ss
ACKNOWLEDGED BEFORE ME THIS �� DAY OF li 20 —Ll— BY
WHO IS PERSONALLY KNOWN TO ME ✓OR WHO HAS PRODUCED
is correct and that all work will be done in
AftINTIFICATIOJ. RHONDA LAFFERTY
C,q-f t r : •; •= MY cOMPION # EE854297
S G ATURE OF N TAR OR PRINT NAME OF NOT Y �.,� . EXPIRES January 08, 2017
COMMISSION NUMBERVON (407) 398.0153 FWkiallotary$°^'ice'C0m
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 04/202010