HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATION1 ^ �`
Date: J _ ee Due: �` Receipt# � Permit # '
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
11 Electrical ❑ Plumbing ❑ HVAC ❑ Fence
❑ Shed ❑ Demolition UGas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialtypermits
1. Location/Site Address: J(q ys-
r
2. Parcel ED Number: SSQ I I —�5 I 1 ^ 00 ( O —I dp n
SLANNED
o'rM
St. Lucie County
pL 3ua"
M'
��j
3. Complete Description.of Project yr Work:
4. Owners formation pa 5. Contractors Information
Name: � Q r� sa'— 0—u FL Reg/Cert #:
vl K.a 1, x_
D-(OS I 5-
Address: SR�S Wpoml/wL�� CountyCert#:
City: State: Business Name: uO ri G -
V (dam
Zip: �j�ir1$ Phone: � J % Phone`(—//7i7 Fax2� 7\ 9i — 17i
6. Value of Construction: $ Q(7)
OWNE ' AFFIDA ce 1Y of the intormation contained in this application is correct and that all work will be i
c p 'an a wi all applicable laws regulating construction and zoning.
owkPlJ JAMEs [D_
PRINT WNER OR CO] RACTOR NAME SIGNATURE OF OWNER OR CONTRACTOR
STATE F FLORIDA, COUNTY OF `
ACKN WLEDGED BEFORE ME THIS DAY OF 20BY��/��-�" ` •�1.J -\ �\ 7�
WHO IS PERSONALLY KNOWN TO ME_ OR WHO HAS PRODUCED DLG- Clc� !9�14 GoN .0 V
AS IDENTIFICATIOi .
I►�
SIGNATURE O 1 OTARY
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 WITH CONTRACT UNDER $7500.00
Revised 04262010