HomeMy WebLinkAbout0706-0402 APPLICATION FOR ELECTRICAL PERMIT4 - �
NIAR,rkR PERMIT:
&CANN 1 PER,:°..LT' NUMBER:
BY
St Lucie Comfy
j So ST. LUCID COUNTY PUBLIC WORKS
/ BUILDING & ZONING DEPARTMENT
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
561462-1553
1. LOCATIONISITE ADDRESS:
2. PARCEL ID NUMBER:
SECT TP RNG W
APPLICATION FOR
ELECTRICAL, PERMIT
SEE REVERSE SIDE FOR INSTRUCTIONS
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DATE: 1%
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3. DESCRIPTION OF PROJECT OR WORK ACTIVITY:
4.
Name:
Address:
City:
Phone:
OWNERS INFORMATION (�
/ II��IiY�S �N�v�riSQS '�'Tf (Vl'C�
2d
44- -f- P �,J State: l�
Zip: �Wq-ja-
6. VALUE OF CONSTRUCTION: $ (? d C)
NOTE: A SEPARATE PERMIT IS REQUIRED FOR A TEMPORARY POLE.
OWNER'S AFFIDAVIT
5. CONTRACTORS INFORMATION
FL REG/CERT #: LEM I(A-3%
COUNTY CERT #:
Business Name: '"lGt'i�tUL EL vic
9 .
FEES DUE:
RECEIPT-5
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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 QUAL I RS/OWNERS NAME g SI iTURE AQUALIFIER11�0WN-NER
CL `�
STATE OF FLORIDA, COUNTY O .p
SWORN TO SUBSCRIBED BEFORE ME THIX"DAY O `
WH ER ONALLY KNOWN TO ME OR WH�O►� HAS PRODUCED
SIGNATURE OF NOTARY TYPE OR PRINT NAME OF ROTS
NOTARY PUBLIC TITLE COMMISSION
1
BY / ;`
AS IDENTIFICATION.
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NOTICE TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PA E OR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LE AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.