HomeMy WebLinkAboutApplication for Electrical PermitMASTER PERMIT:
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1.
2.
3.
LOCATION/SITE ADDRESS:
PERMIT NUMBER: I 0I010f1 ?
ST. LUCIE COUNTY PUBLIC WORKS
BUILDING & ZONING DEPARTMENT
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
561-462-1553
APPLICATION FOR
ELECTRICAL PERMIT
SEE REVERSE SIDE FOR INSTRUCTIONS
DATE: /- 5--0/
Iva ADD'eESS -- I'Z o,PiD.4 Ty,0�VPIA`C
PARCEL ID NUMBER: /225-33/- 000/- 000/e 1 otl /
SECT TWP RNG MAP IU ZNG r)� LU rj INIT
DESCRIPTION OF PROJECT OR WORK ACTIVITY: L /Gyr-5 -'O,P OFF-Z��/ sF E16AI
4. OWNERS INFORMATION 5. CONTRACTORS INFORMATION
Name: OLC' 1A.10. FLREG/CERT#: 00o2 y$0
Address: R, 0. fgo x 141019 COUNTY CERT #: / 8 75/ 8
City: State: Business Name: RoA1f1LD SCN4Y1/T7-
Phone: 5"6 /- 116 y - 5977 zip: 3V079- 5'0/9 .
6. VALUE OF CONSTRUCTION: $ 2, 00C. FEES DUE: 7 7• ®D
NOTE: A SEPARATE PERMIT IS REQUIRED FOR A TEMPORARY POLE.
OWNER'S AFFIDAVIT:
RECEIPT: Of 1 333D,
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.
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PRINT QUALIFIERS/OWNERS NAME
STATE OF FLORIDA, COUNTY OF S E141AIOZ F
SIGNATURE OF QUALIFIERIOWNER
SWORN ND S665ER16€Q.11E OGRE ME THIS S DAY OF S4^ , 202/, BY/�A1D P S'C!!�f/Tr
WHO I PERSONALLY KNOWN TO ME O HO HAS PRODUCED AS IDENTIFICATION.
DAVID CHDLAK
✓ / D C <-1O L/�!� taoTARYC N 0 C0OF
29 FLORIDA
EXPIRES V
SIGNATURE OF N TARY TY E OR PRINT NAME OF NOTARY eoNOEOTHRun�i+9 OTARYt
NOTARY PUBLIC TITLE �C -7-3 2 COMMISSION NUMBER
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.