HomeMy WebLinkAboutApplication for Electrical PermitMASTER PERMIT:
PERMIT NUMBER:o1 / 51-0 I?/
1.
2.
3.
LOCATION/SITE ADDRESS:
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/
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PARCELID NUMBER:
/22 S - 33/- 000/ - 000/8
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DESCRIPTION OF PROJECTOR WORK ACTIVITY: 5/6,V
4. OWNERS INFORMATION 5. CONTRACTORS INFORMATION
Name: OLC I've. FLREG/CERT#: '!5L? —0002 17/50
Address: R. O. ,U X /y O/9 COUNTY CERT #: / 8 7Z/ 8
City: f T. pleRL 6- State: c'L Business Name: RoAml—p D. scq4 -r7—
Phone: 576/- 1/6-/- 5977 Zip: 3Yg79- 410/9
6. VALUE OF CONSTRUCTION: $ 2, 000, FEES DUE:
NOTE: A SEPARATE PERMIT IS REQUIRED FOR A TEMPORARY POLE.
OWNER'S AFFIDAVIT
RECEIPT: of 13 3 - ML
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 6101- /O L F
SIGNATURE OF QUALIFIERIOWNER
SWORN AND Rl6 EFORE ME THIS S DAY OF.TA/✓ , 20 d/, BYRv�✓�LD /Ni:!(TT
WHO I PEITSONALLY KNOWN TO ME HO HAS PRODUCED AS IDENTIFICATION.
l�Lt/� �/� ✓ l %% C %[ /l NOTARYPuSL AFLORIDA
SIGNATURE OF NOTARY `�E OR P INT NAME OF NOTARY CDM�
NOTARY PUBLIC TITLE @C 4k - 2-9 � COMMISSION NUMBER eONOW� S�1vI- '
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.