HomeMy WebLinkAboutSUBMITTED PAPERSF; t CS aR [ D Fi
Planning & Development Services
Building & Code Regulations Division
/ 2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing ❑ HVAC ence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: )/ .
2. Parcel ID Number: 3SI $-311 - CXx'a3 — 000 — S
Office Use
Only
Section
Township
Range
Map Page
IZvning
La Use
Initial
IN"
3. Complete Description of Project or Work: �p�- �� 1.;r1. C IL- 1 — `t ,-1 1— 5" S'ralo �9coo
I0V — 111 c/L I �9' —S-;� 11 1�AA' rescA
4. Owners Information � `mbeC�'Eiy � 5. Contractors Information
Name: NC)r'ma n Q) , U (J'A e l l FL Reg/Cert #:
Address: an \'ZI eJ�Qi �P i �,t,p County Cert#:
City: State: FL Business Name: S-7hAPA `t CQ C-0 rv\
Zip: 'Z)l 9 k - Phone lr �9� �d—`'Phone: 77a—�$� I15(Fax: 772—�$g— 3035
6. Value of Construction: $ )'/
OWNER'S AFFIDAVIT: I certify that all of the information contained it
compliance with all applicable laws regulating
eheFksls .1. t2�c`r./vbr�
is correct and that all work will be done in
PRINT OWNER OR CONTRACTOR NAME SIGNATURE OF OWNER OR
STATE OF FLORIDA, COUNTY OF ff�0,H-1^
ACKNOWLEDGED BEFORE ME THIS I DAY OF 1i, 20 0- BY �1�2
WHO IS PERSONALLY KNOWN TOM1?_)t- OR WHO HAS PRODUCED
AS IDENTIFICATION. "pray'••.,
JI BUFORD
��l V�.� rC1 '= MY COMION #FF076468
SIGNATURE OF ARY TYPE OR PRINT NAME OF NOTARY _•; •....... °'`
••.•,!poF�oP,•� I=XARES December 12, 2017
COMMISSION NUMBER F FO 6 (407) 398•0153 Rod dallotaryService.com
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 04/26/2010
1
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