HomeMy WebLinkAboutSPECIATLY PERMIT APPLICATIONFee
Permit # 1 Lk is l -
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
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❑ Electrical Plumbing ❑ HVAC ❑ Fence
❑ Shed 9 Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: ZO to /o 6 S fJ S !1
2. -Parcel ID Number: _-,2 4i i �l — S'f� i ; 'lg 0 Z
OWce Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Work: 4: �- y - I'L "jqJ
a
4. Owners Information ' 5.. Contractors Information
Name: %Z FL Reg/Cert #:
Address: / 06;&
City: (J)SL , State:
Zip: 3�17 Phone:
oa
6. Value of Construction: $
County Cert#:
Business Name:
Phone: fl Fax:
l�
OWNER'S AFFIDAVIT: I certify that all of the information cones�}} in -this p
fion i
m ance with all applicable laws r g'u-latmi g an
PRW OWNER OR CONTRACTOR NAME SIGNATURE OF OWNER OR
STATE OF FLORIDA, COUNTY OF Sk ` ly \ P
ACKNOWLEDGED BEFORE ME THIS
WHO IS PERSONALLY KNOWN TO ME OR WHO HAS
AS IDENTIFICATION.
SIGNATURE OF NOTAn
COMMISSIONNUNBER 1 _L4, 16%l CO 1
20' l_,BY .It��c7� sJUd 4t��
in
Pf/9 ��i
DEANNA GIVENS
`�1pHY
� ;
Notary: Public - State of Florida
•;
My Comm. EVay Dec 16, 2016
NOTAR
Commission # EE 858761
OFF�°p,�
�, nog
Bonded Through National Notary Assn.
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 V500.00
Revised 04/26/2010