HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONi I
Date: 12. j Fee Due: .a(o
❑ Electrical
❑ Shed
i 9n I
Receipt Co 303 I Permit
i Planning & Development Services
Building & Code Regulations Division SC,q
2300 Virginia Ave. NN�p
Fort Pierce, FL 34982 St
(772)462-1553 UCie C
oL1n41
SPECIALT ER1N1IT APPLICATION
❑ Plumbing HVAC ❑ Fence
❑ Demolition ❑ Gas ❑Siding
i
Seepage 2 for instructions and additional paperwork required for speciairy permits
1. Location/Site Address:
2. Parcel ID dumber: 3g1Q ^ 509 — Oa -25-0 — Ot()
Township I Range I :Map Page I Zoning I Land Use I Initials
Office Use Secuon
Only
3. Complete Description of Project or Work;
4. Owners Information // 5. Contractors Information
Name: / ; ) p/ L , �� � C.(j Zn C: FL Reg/Cert N:
Address: % UL j, j0)CLt[ . -- l-eS t7/ lZ County Certn:
City: State: Busin ss dame:
Zip: Phone: Phone. -C.i Itib
6. Value of Construction: S -�33 i1 . Uv
Cam 4��
3m-coctsv- wc-,
_Fax: 77o2—J(66'319S
OWNER'S AFFIDAVIT: I certify that all of the information contained in this pp 'catiod chat ail work will'be done in
com fiance With all applicable Taws regulatins co tru oy*q
v
PRINT OWNER OR CO P.CTOR N SIGN, OF OWNER 0 CONTRACTOR
3TATEOFFLORIDA iCOII-INTI''OF
ACKNOWLEDGED BEFORE ',IE THIS DAY OF :0 3Y ►�1
OR WY HAS PRODUCED
AS IDENUIWATION
f e Q T ACY LANGEZ
I NOTARY *PUBLIC
i U E OF . OT..R TYPE OR PRIM P IE OF NG Y STATE CF FLORIDA
COMM1 SIGN NUMB R
Comma E5021924 .
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
LENDEROR.AN-ATTORNEY BEFORE RECORDING YOUR,.NOTICE OF COMN(ENCEMENT.
E,X-EM' PT: AJC-aEATR-EPI ICE-MENT"WITH CONTRACT UNDER 57500.00
Revised 04126i2010
12/05/2013 14:22 7724663053 SEACOAST AC PAGE 01
laaee: I a 6 I3 Fee Recri O
Plafal ing & Developmear Services
Baa.ilding & Code Re ul;arions Divisioc
2300 Vir=inia ,-eve
Farr Pierce. FL 34992
(772)46�1-1553
SPECIALT - PER UT APPLICATION
❑ Electrical ❑ Plumbing HV-AC ❑ .Fence
❑ Shed CI Demolition ❑ Gas Cl Sidi.n.g
yen page 3 for instructions and additiormi paperwork required f )r speciairy perrrrits
1, I,.pcation/Site Address:
2. Parcel ID .Number:
Town9hip Range loop ?')Lit Zoning L:m[i UseI Initials
Office rlse sec`,on
Only � I I
I
a�. Complete' DescriptJon of Project Or Work: `
4. Owners Information 5. C:oatrslcsors 1.Qf0rmation (he
l ^ Lamle: C.�� C FL Re�/Crrt r: C)
address: G County Cert4: rlj J S,5
Cl[yr'190ek State: Burin `ss `lame:
Zip: Phone: Phrine --
h. Value of Consirimtion:.S 1-7
OwNFR'S.AFFmAVI-r; i certjfv drat all of [Ile inf0rmaticn xntained in dlis It p cltion is Jr c a c.171[ •,111 +,vrrj •Vial re �c;ne ;❑
�omr�liarlca .vith all apolicabic law; e2ulatin; c[) tnticrl�ap! ' 1}I�1
4TI T '.�I.V�JER,)R.
`TATE OF Fi,,)R1DA, .;r,.+, I--: ,',F
A(-*'; Ql()w'I_'i)GLL 3F,F�)U- Yff_ -, ".!Is
TRACY--Ai-4GZL
r�, Lam£ !! QT.:li . �(F. C F �!f NOTARY PUawc
'--' 'f STATE Or 1�i,1FtlC�A
MNfiSSION
:o�ti��ng z `-'� COMM#E9021'924
�"lnlw.[ AJGR�pFj7�,
NOTIc><'ro OwN n• 1'.•v11,.1)RE TO RECORD .� NOTiCS: OF C()MMEN(:7iV[EyT MAY RESi!t'r L-[ YoUA TWICE AYINC
°' L FOR IMPROVEMENTS TO }`1)1j-R. PRQpER•TY. IF YOU INTEND TO0[3T:\Iiv F1!`1A,VCi`1G, 1-0v$iJ1.T WITH1'fj11R LE`rDER,i),R:,,�iV•,�TTORiVR1' UUOU RECORDrN , ypi)R .`IOTI(-T pF Cc)rv(Mk;VC1:N ENT.
It'I T:.a ,'-HE,�TR�EPLA F,MCNT WIT14 CONTRA(? rj-4DER 57{Oo.IH)
Revleed Ud/.��20111