HomeMy WebLinkAboutApplication for Electrical Permit1
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MASTER PERMIT:
PERMIT NUMBER: 01676 F 0
1.
9
3
ST. LUCIE COUNTY PUBLIC WORKS
y BUILDING & ZONING DEPARTMENT
V,. 2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
5611-462.1553
LOCATION/SITE ADDRESS:
PARCEL ID NUMBER:
APPLICATION FOR
ELECTRICAL PERMIT
SEE REVERSE SIDE FOR INSTRUCTIONS
DATE:
/►/O fIDD''ESS
DESCRIPTION OF PROJECT OR WORK ACTIVITY: L /G1-/TS —�OR oFF-/�iP>z'i19/ sE S16AZ
4. OWNERS INFORMATION
Name: 01-6. /NC.
Address: P.O. /.30 x /y 0/9
City: f T pleR L46- State: �L
Phone: 56 /- 416 -/ - 5977 zip: 35/979- 1-/019
6. VALUE OF CONSTRUCTION: $ 2. OE0.
NOTE: A SEPARATE PERMIT IS REQUIRED FOR A TEMPORARY POLE.
OWNER'S AFFIDAVIT:
5. CONTRACTORS INFORMATION
FL REG/CERT #: i�-C' — 00 0 2 y 5 0
COUNTY CERT #: / 8 7 z/ 8
Business Name:
iP 0,Vf1 LP D. S C/-/41 /TT
FEES DUE: 7 1• 0-0
RECEIPT: 0 U 33 3 9 D
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,
PRINT QUALIFIERS/OWNERS NAME
STATE OF FLORIDA, COUNTY OF 56MI-✓y1-F .
SIGNATURE OF QUALIFIERIOWNER
SWORN TO D RE ME THIS S DAY OF S4 , 20-EZ BY�CaNA1/i.4 2?1y1q /TT
WHO IS ER ONALLY KNOWN TO ME OR HAS PRODUCED AS IDENTIFICATION.
DAVID CHOLAK
NOTARY PUBLIC - STATE OR FLON115A
Gli(/ DST I✓ C%i �L�/t COMNHSSION # CC9E32%
SIGNATURE OF N TARY PE 0 P INT NAME OF NOTARY 1/2004
�y BONDED TXMF4R O!®=NdtARYi
NOTARY PUBLIC TITLE L4 9 3 2 Tg 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.