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DESCRIPTION OF WORK:
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PERMIT INFORMATION
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PROPOSED USE:
TYPE OF CONSTRUCTION: (CHECK ALL APPROPRIATE AREAS)
1RESIDENTIAL: COMMERCIAL: X INDUSTRIAL: OTHER:
NEW CONSTRUCTION: ✓/ EXPANSION OF EXISTING BLDG:-
INTERIOR REMODELING: OTHER (SPECIFY):
EST. COST: J5 o Cyu c
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STATE OF FL Q�W• /CERT #: C (-{C, frc ,I ,t u 7 COUNTY CERT #-yy-Z T
CONTRACTOR NAME: Ae O 1 G l �u 5
i ADDRESS: �3' G•�SSn tf
CITY: P S L STATE:
ZIP: 3 Al 9A PHONE
ARCHIT/ENGINEER: A &, + 16,rJr fj L,..-A
ADDRESS: % I [" ,u -, A.^Ee I. -
CITY: f4 p cz STATE: rI-4
ZIP: JY�I'3Z PHONE #: (/J? ) '5"66 "'746,9 y
BONDING COMPANY:
ADDRESS:
CITY:
MORTGAGE &ENDER:
A MRESS: C,
CITY:
STATE:
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STATE: FLU
ZIP:
ZIP:
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INFORMATION
PROJECT ADDRESS: �
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/SUBDIVISION: KQ;L'o- P-,V JAL. LOT:
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PROPERTY TAX ID #: 3 % I 55 � o
"PARCEL SIZE (ACRES OR �SQFT.)
,--LEGAL DESCRIPTION:
OWNER NAME: L-cQl*AR\) (Y) H4.-1 Z r'lc,
BLK:
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ADDRESS:
CITY: zz STATE:
ZIP:
PHONE
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IF -THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE OWNER
LISTED ABOVE, PLEASE FILL IN NAME AND ADDRESS BELOW -
FEE SIMPLE TITLEHOLDER:
ADDRESS:
CITY:
STATE:
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ZIP: