HomeMy WebLinkAboutSUBMITTED PAPERSFee Due:
Permit #
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave. .
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
Electrical ❑ Plumbing ❑ HVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
See page 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address:
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2. Parcel ID Number: `� o� - 5 00 - 00 Lo-1- ' `) ('7 ()I �
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Work: Ne4 rc C o "
J
4. Owners Information 5. Contractors Information
Name: L O e- q O rp—y--�S FL Reg/Cert #: E-C- 00(D a9 3
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Address: ` Q County Cert#: -C L O ✓ S
City: _ State: 1 Business Name: � l e C-0--1 C �f'1Y) �� 6y--'
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Zip: 3" 9 `T Phone: a &3 - Q Qti L0 Phone: 5>3ta la L 19 Fax: rj ,q
6. Value of Construction: $ J00"7'
OWNER'S AFFIDAVIT: I certify that all of the information contained in this application is correct 'nd that all work Will be done in
1 compliance with all applicable laws regulating construction and zonin
` C� nA \� 1 aa-' ry-m�
PRINT OWNER OR ONTR OR`, - 1 SIGNATURE OF O R 6R CONTRACTOR
STATE OF FLORIDA, COUNTY OF ST • l �V 1 C
ACKNOWLEDGED BEFORE ME THIS �.1f DAY OF CaY119C'✓Vb LL BY
WHO IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED
AS IDE tom v.AV._%•• _SWAN T. BROMELOW '
t COMMISSION EE
se
' _ ( PIRES: October
r 17,2014 2014
SIGNAT TYPE R PRINT NAME OF NOTARY Bonded Thru Notary Public Underwriters
COMMISSION NUMBER )EEC3 qq
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