HomeMy WebLinkAboutApplication for Electrical PermitMASTER PERMIT:
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LOCATION/SITE ADDRESS:
PERMIT NUMBER: o /o / 0 a r7 9
ST. LUCIE COUNTY PUBLIC WORKS
BUILDING & ZONING DEPARTMENT
23DO VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
561-462-1553
APPLICATION FOR
ELECTRICAL PERMIT
SEE REVERSE SIDE FOR INSTRUCTIONS
DATE: /- S-o/
I/O ADDkess 42` -Z o,P1D.4 7-61-10yPl C
PARCEL ID NUMBER: 12 26 -333- 000 /-000/7 (�tJ l
SECT TWP 34 1 RNG 39 MAP joU2 ZNG 65 LU 1 OG7,5 INIT
DESCRIPTION OF PROJECT OR WORK ACTIVITY: L /Gyrs LOR OFF-/.P>-,Ii sE 9/&Al
4. OWNERS INFORMATION 5. CONTRACTORS INFORMATION
Name: OLC' /Al/C . FL REG/CERT#: 2 4150
Address: P.O. BO x /y O/9 COUNTY CERT #: / 8 74/ S
City: C-r. plepe6- State: FL Business Name: RO.V41-,P D. SCIV4.11TT
Phone: 576/- N64/- 5977 ZIP: 35'979- y0/9
6. VALUE OF CONSTRUCTION: $ 2, 000. FEES DUE: 71,6-6
RECEIPT: ° 1 3 3 3� q
NOTE: A SEPARATE PERMIT IS REQUIRED FOR A TEMPORARY POLE.
OWNER'S AFFIDAVIT: 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 SIGNATURE OF QUALIFIER/OWNER
STATE OF FLORIDA, COUNTY OF SEh1�NOLf
SWORN T Q SUBSCRIBED BEFORE ME THIS S DAY OF 5,4N , 20d l BY)POALD P SC/y/t1/Ti
WHO IS ERSONALLY KNOWN TO WHO HAS PRODUCED AS IDENTIFICATION.
r DAVID CHOLAK
i>rQ / b C H O L i� ( NOTARY PUBLIC - STATE OF FLORIDA
SIGNATURE OF NOTARY TYPE ORV31NT NAME OF NOTARY COMMINWI 832 CC998
EXPNOTARY PUBLIC TITLE C' LI $ 3 2 `J ?3 COMMISSION NUMBER BONDED THRUASAYI-89&NOTARYI
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,