HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONI Fee Due:- )t4,lsZl I Receiut# I Permit # ltA)r) - DQ71., 1
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❑ Electrical
❑ Shed ❑
St. Lucie County Building & Zoning
2300 Virginia Avenue Ft Pierce, FL 34982-5652
Tel. 561-462-1553
SPECIALTY PERMIT APPLICATION
Plumbing ❑ HVAC
Demolition ❑ Gas
❑ Fence
❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: P:r)ic c �11: i (fin Ern6 L I
2. Parcel ID Number: �?j`C� 000
Office Use
Section
. Township
Range
I Map Page
I Zoning
Land Use
I Initials
only
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34
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3. Description of Project or Work Activity:
4. Owners Information 5. Contractors Information
Name: }4u cp FL Reg/Cert #:
Address: 1 �A ICdIQJ_i )y 6 � County Cert#:
City:. ' C'e State: Business Name:_ 'R sc-)"x m, S-�
Zip: ��q5 t Phone: 1 .Phoneme D Fax) �31 ��Z
6. Value of Construction: S
OWNER'S AFFIDAVIT: I certify that all of the information contained in this ap ' ation is cc t. and that all work will be done
'in compliance with all applicable laws regulating cons c ' nand wnin' .
•'?t PRINT QUALIFIERS/OWNERS NAME SIGNATURE OF QUALIFIER/OWNER
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STATE OF FLORIDA, COUNTY OF
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SIGNATURE OF NO 1
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TITLE: NOTARY PUBLIC
e:lo CLrd ACKNOWLEDGED BEFORE ME T1HS�� DAY OF
WHOI ERSONALLY KNOWNT ORWHO HAS PRODUCED
CQ�PISI6XYDAi`.JJ I. I.M.
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St Lucie County Specialty Permit Application rev. 8/25105 drag