HomeMy WebLinkAboutapplication Dates 3 a1 13 Fee Due: �; l,a Recei t# 13 6 permit# k303-030
Planning&Development Services
Building&Code Regulations Division
® 2300 Virginia Ave.
Fort Pierce,FL 34982
--- (772)462-1553
SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing ❑ HVAC 13/Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
See pae e 2 foojr insttructions and addhional paperwork required for specially perndis
1. Location/Site Address: n �Q b Noa 5 Aio
2. Parcel ID Number: 001 9
Township Range Map Page Zoning Land Use Initials
Office Use Section
Only
3. Complete Description of Project or Work: (p 1 H W OFF4�6Nt
CAW V d CU I - LA)0
4. Owners Information. 5. Contractors Information
'Name: 6)1,P y�'/ �G nLk V I l>°m FL Reg/Cert#:
Address: U N(JQL S County Cert#: a 73��
City: U Y U State: j! Business Name: ekO*UaWL
Zip: 1� (y Phone: 53 l r Phone: 3 O-JZ Fax: ,3ge'g z i 6
6. Value of Construction:S �/U
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 reD 1 ' 6 construction an oning.
PRINT OWNER OR CONTRACTOR NAME SICKATURE OF OWNER OR C ACTOR
STATE OF FLORIDA,COUNTY OF 10
ACKNOW-LFDGED BEFORE NJE THIS a DAY OF C 20 k S ,BY �)«hA d h Or\c�
WHO IS PERSONALLY KNOWN TO ME R WHO HAS PRO `L Q L C-
AS IDENTIFICATION. „ pFpNNA GWEN8
Public•Sbte o1 Ftaiidt.
My Commal;,��g Dec 16;2016
SIGNATURE OF NOTARY TYPE OR PRINT NAME OF NOTARY" ?•.•
s ml on i1 EE 06576. "
whimCOMSSION NUMBER
MI
NOTICE TO OWNER: 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.
EXEMPT:A/C-HEAT REPLACEMENT RTTH CONTRACT UNDER$7500.00
Revised 04t26/2010