HomeMy WebLinkAboutApplication for Electrical Permit` A
PERMIT NUMBER: A/ 0 / 00 iC A
MASTER P, RMIT:
1.
2.
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LOCATION/SITE ADDRESS:
PARCEL ID NUMBER:
SECT I I TWP
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: /- S-o/
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DESCRIPTION OF PROJECT OR WORK ACTIVITY: L /G1-/rs Foie oFF-/o�P>z'iY// sE 916"1
4. OWNERS INFORMATION 5. CONTRACTORS INFORMATION
Name: OLC', /it/C._ FLREG/CERT#: 4�7C —0002 4/50
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Address: R. O. 6o X /L/ 0/9 COUNTY CERT #: / 8 74/ 80
City: f'T pl aRL4E State: Business Name: RoA1,4i p D. scg4-!/TT
Phone: 576/- /�6y- 5977 zip: 3y979— 4/o/9
6. VALUE OF CONSTRUCTION: $ 2, 000, FEES DUE: (30
NOTE: A SEPARATE PERMIT IS REQUIRED FOR A TEMPORARY POLE.
OWNER'S AFFIDAVIT:
RECEIPT: 0(1333q 1
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 Ehi/,-✓vL E
SIGNATURE OF QUALIFIERIOWNER
SWORN SCRI ED-BEFGR ME THIS S DAY OF S4A/ , 20.e-L, BYRO-✓'fC.D s! 1r7
WHO I PERSONALLY KNOWN TO ME OR HO HAS PRODUCED AS IDENTIFICATION.
DAVID CHOLAK
NOTARY PUBLIC - STATE OF FLORIDA
D A d l D V—W o LAK COMMISSION # CC983298
SIGNATURE OF FOTARY a PETS OF�PF3INT NAME OF NOTARY
NOTARY PUBLIC TITLE Cof / 2 fir' COMMISSION NUMBER DEDTHRu ry
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.