HomeMy WebLinkAboutApplication for Electrical PermitMASTER PERMIT: PERMIT NUMBER: 00 77
�Q1 010041
JG`e COST. LUCIE COUNTY PUBLIC WORKS
v BUILDING & ZONING DEPARTMENT
-1 23DO VIRGINIA AVENUE
V11 FORT PIERCE, FL 34982-5652
$61-462.1553
APPLICATION FOR
ELECTRICAL PERMIT
SEE REVERSE SIDE FOR INSTRUCTIONS
DATE: /- 5--0/
LOCATION/SITE ADDRESS: A10 42)P eESS *' -- TvoPVRIIKC
PARCEL ID NUMBER: / 226 - 333- 0002 -00
SECT I _J a I TWP I C `i Cl- I RNG ILA 1 MAP 1 /-W5 1 ZNG �� I LU I [,/(�� � UNIT
DESCRIPTION OF PROJECTOR WORK ACTIVITY: L /Gyrs L0,,9 916,V
4. OWNERS INFORMATION
Name: OL e . /'vC .
Address: ;0. 0. /go x 141019
City: f'r. P11--RL4E State: �L
Phone: 56/- //64 - 5977 zip: 3y979- 41019
6, VALUE OF CONSTRUCTION: $ 2, 000,
NOTE: A SEPARATE PERMIT IS REQUIRED FOR A TEMPORARY POLE.
OWNER'S AFFIDAVIT:
5. CONTRACTORS INFORMATION
FLREG/CERT#: 15-C — 000 2 z/SO
COUNTY CERT #: / 8 74/8
Business Name: Ro"V41-0 D. SCNy//TT
FEES DUE: 17° d
RECEIPT: 01133 3g,0
I certify that all of the information contained in this application is correct and that all work will be done in compliance with
all applicable laws regulating construction and zoning.
110ON,11LP. sCNMiTT
PRINT QUALIFIERS/OWNERS NAME
SIGNATURE OF QUALIFIER/OWNER
STATE OF FLORIDA, COUNTY OF SE1'411yt7 C-E.
SWOR SUBSCRIBED BEFORE ME THISS DAY OF SAN , 200 BYeW CL� P-SCN/y/TT
WHO I P SONALLY KNOWN TO M WHO HAS PRODUCED AS IDENTIFICATION.
DAVID CHOM
D /4y /.D NOTARY PUBLIC- STATE OF FLORIDA
SIGNATURE OF OTARY PE 0 P INT NAME OF NOTARY �a�l3v
NOTARY PUBLIC TITLE �e 32� COMMISSION NUMBER BONDED THRU ASA I.M.NOTARY1
NOTICE TO OWNER: YOUR 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.