HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONPlanning & Development Services
Building &Code Regulations Division
2300 Virginia Ave. Sc
Fort Pierce, 'FL 34932
(772)4624553 St `4C/@ O
SPECIALTY PLRA41T APPLICATION
Electrical ❑ Plumbing ❑ RVAC ❑ Fence
/❑ Shed ❑ Demolition ❑ Gas . ❑ Siding
See page 2for instructions and additional paperwork requiredfor speclalty permits
1. Location/Site Address: c'j A +!
2. ParcellD Numher: qs o -A," S'a I ` 01 q,r 0oey 2
In
Office USE'
Only
Section
Township
Range
Map Page
Zoning:
'Land Ilse
In Ila
3: Complete Description of Projector Work: j2 c. ,p /�t:l t. Yyt e -i� tom- �t� r'a
4. Owners Information .5. Contractors information t r�
Name: `74yi t l .t 6, E" � -L FL Reg/Cell #: ` j. (� "1 t
,�I t 1
Address: 8'U �C/i- 1 � � � _ County'Cert#:
� � 1 (, ci.4
City: S4v/�, �'- State: ���' Business Name: t-_�'�'s�,. 1;:'t�s� +��r .ice. ,,. i
Zip: CI r'I, g Phone: Ah'7- .A lo.( 3. Phone 70 4 1,51 Pax: `a " ..59 i
6. Vahie of Construction: S . % o S e)
~F.R'S AFFIImAvrl: i certify that all, of the information contained:in.this application is correctandthat all work will be done in
compliance with a]I applicable laws regulating con Iuct' n and.zoni &
PRINT OWNER OR.CONTRACTOR.NAME SIGNAT OF OWNERORCONTRACTOR:
STATE OF FLORIDA, COUNTY OF 1I'1 G K`�'\ N
ACKNOWLEDGED BEFORE ME THIS DAY OF. /S-i 20 - BY _ ! GV�
WHO::ISPERSONALLY KNOWN TOME _—ORWHOHASTPODUCED\ T-kv11 rS V—ASimIL-�) S''
AS IDENTIFICATION-
J IfATHRYAI BUMBERA
4,4111)Explres
*TAFtY PUBLIC'
SIGNATURE (' • NOTARY T TYPE OR PRINT AML OF NOTARY STATE .tiF FLORIbA.
COMMISSION.NUMBER 11�1) � t t Comrf# DD967559
93/3i201.4
NOTICE To ONVNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENTMAY RESULT IN 'YOUR PAYING TWICE FOR
INIPROWMANTS "TO YOUR PROPERTY,. IF YOU INTEND TO OBTAIN TINANCINC, CONSULT ITtf YOUR
LENDEROR AN ATTORNEY'BEFOiZE RECORDINCYOUKNOTtCE OF CONIMENCEMENT.
xENIPT: A/C-HErCT REPLACEMENT WITH CONTRACT UNDER S7500.00
Revised 04126/201.0