HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONPermit #
Planning & Development Services
T Building & Code Regulations Division
p 2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553 Fax 462-1578
SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing ❑ HVAC Fence
❑ Shed* ❑ Demolition ❑ Gas ❑ Siding
See page 2 for instructions and additional paperwork required for specialty permits
7v 1. Location/Site Address: / OA m I r W es w' 4'ekkz-
2. Parcel ID Number: V 30 I -�O 3 - DO) t "- 000 -
3.
of Projqjct or
{r nC` rf /-' ill SrAL s r dz i
4. Owners Information
Name: "`Z• c-K
Address: L/i I ? !�` OkAer OI`
SCANNED
BY
St. Lucie Countv
n 6a�K Ywa{ 6
02C 2A.S"C
5. Contractors Information
FL Reg/Cert #:
County Cert#:
City: 14 le;e—k State: VA Business Name:
Zip: a.3y SJ' phone: 7S7-513- 90.19
oa
6. Value of Construction: S
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 ning.
111C.t� `c6/Draeki
PRINT OWNER OR CONTRACTOR NAME SIGNATURE OF OWNER OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF S Jr • uG� � (� t,, S
ACKNOWLEDGED BEFORE ME THIS �f DAY OF V —20 \ ,BY 1-•��'~ �•�k�•C SC��\
WHO IS PERSONALLY KNOWN TO MEO HOHASPRODUCED1 rl �o i.�•O a^S
DEANNA GIVENS
AS IDENTIFICATION. o
.'z`, ;`o; Notary Public -Slate at Florida
a a vA.n aG A L c My Comm. Expires Dec 16, 2016
SIGNATURE Of NOTA , '; P Bonded
Through
N ti EE 968761
�t car �t TYI E OR PRINT NAME OF NOTARY '';FOF I�Q.�
COMMISSION NUMBER F—IWA C,1 Bonded Through National Notary Assn.
*ALL RESIDENTIAL. AND NONRESIDENTIAL STRUCTURES ARE REQ11RIED TO MEET THE FLOOD ZONE
ELEVATION OR 18 INCITES ABOVE THE CROWN OF THE ROAD, WHICHEVER IS APPLICABLE. (see instructions on
reverse side of this sheet)
Revised 03/19/2014