Loading...
HomeMy WebLinkAboutSUBMITTED PAPERSDate: % A ee D Fue: �, G, Receipt# fo Permit # O a oA 0 1 q Planning & Development Services . SC NNED Building & Code Regulations Division BY CO St. Lucie y 2300 Virginia Ave. Unt Fort Pierce, FL 34982 (772)462-1553 SPECIALTY PERMIT APPLICATION ❑ Electrical ❑ Plumbing ❑ HVAC I Fence ❑ Shed ❑ Demolition ❑ Gas ❑ Siding Seepage 2 for instructions and additional pa�perrwoi* required for specialty permits 1. Location/Site Address: -5—V// 2. Parcel ID Number: Office Use Section Township Range Map Page Zoning an Use Initials Only 3. Complete Description of Project or'Work: 2ob' G'fs 4 41od�,/%� 6'y�16y 441al 4. Owners Information/ 5. Contractors Information Name: 4076/G� Z/ 4 FL Reg/Cert #: Address: �y // y/ r� D`r County Cert#: - City: r //" State: �� Business Name Zip: 3y��<L Phone: Phone: 6. Value of Construction: $ cP,-/-- (3z 23� � © Fax: OWNER'S AFFIDAVIT: I certify that all of the information contained in this application is correct d that all work will be done in compliance with all applicable laws regWUREOF n n PRINT OWNER O CONTRACTOR NAME SI ERR O' RA OR STATE OF FLORIDA, COUNTY OF SN . ,- ACKNOWLEDGED BEFORE ME THIS 1% DAY OF WHO IS PERSONALLY KNOWN TO ME_ , I R WHO HAS 20 ,BY. M\C�c�e� myscdl •,o�PKYP�e�, DEANNA GIVENS IDENTIFICATION. ?_ .. Notary Public - State of Florida P_ q\A G— V %:4\ - +:P My COMIr..sgxqires Dec 16, 2016 SIGNATURE OFIIOTARY t '1 TYPE OR PRINT NAME OF NOT0FJ �oP Commission # EE 858761 G S� 1 rD Bonded Through National Notary Assn. COMMISSION NUMBER 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 S7500.00 Revised 04/26/2010 2 L70 / 0 D dPlicant has been advised NO structures can be erected within any easement or right of way unless otherwise approved, Applkmt InftWb-'•'iW i 1/ /S,-GA �V10", �Lr6�h 9,or- I /S