HomeMy WebLinkAboutSpecialty Permit ApplicationDate: I Fee Du, I
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I Receipt#
Planning & Development Services
Building a$ Code Regulations Division
2300 Virginia Ava,
Fort Pierce, FL 34982
(772)462-1553
1 Permit #.
r201-0gqj
SPECIALTY PEPIMT APPLICATION
0 Electrical
❑ PlumbingAC
13Fence
13Shed
❑ Demolition
Gas
❑ Siding
See page Zfor batraetrans and adNidoiral operwark-,rM.Fafrrad� f�or.,spmi4hy permds
1. LocatioD/siteAddress: `��..�� w h�_�.1xiC..
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2. ParcelIDNumber. .�eJa�7 ~6� �ckz'"CO
Off. Use Sertian
Township Range I Map Page ZO�Ig�
LandUse
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3. Complete Description of Pro'ect or 1VorR:
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4. Owners Information (� S. Contractors Ltformation
Name: �Yt.IdICA�S.r�gO�ir;, tri
1-A'i a
Address: AAAC 20,1-00ML Rl %I&—
City: State: �l
Zip: 3 V a p l t phone.
6. Value of Construction: S 368-. ;,Cb
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FL Reg/Cert #: jp - Cr -J VR O% I
County Cert#: `-'LA,--X0
Business Name: Gpirw-s 1 J072U7r�Q PILQ,
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OWNER'S AFFIDAVIT: I certify that all of the mfi:metiencaPax
t@ud th0t a0 work will be dppe ycompliance with all applicable laws rPRINTOWNER ORCONIRACTO NCA`A`E ACI'OR
STATEOFFLORIDA,COUNfYOF ST_ tAIN.Ip, t y\
ACKNOwI,eDOm BEFORE ndETTttS--,OO/��-DAY OF ,zO� ,HY ,vIeA r CYrtmps,
WHO IS PERSONALLY KNOWN TO MEI OR Wa0 [Lu PRODUCED
FI
CATION
SI NATUR FI EOR PRINT NAME OFN TA�RY t1y}A98I0I��Neyyl
COMMISRIONNUMBER�I�rr�� jr7l.JC15 I M-0 IfrMe071w NlywTa:en4amnera
NOTICETOOWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAyI1NC TWICE pOR
IMPROVEMENTS TO YOUR]PROPERTY. IF YOU MIEND TO OBTAIN FINANCING CONSULT WRR YOUR
LENDER OR AN ATTORNEY BEFORE RECORDIINGYOIM NOTICE OFCOMMENCEMENT.
E=n T: AfGHEAT REPLACEMENT �vrO CONTRACT UNDER s7s00a0
Resiled 04126/2010 '
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