HomeMy WebLinkAboutSUBMITTED PAPERSDate: AN No I Fee Due: Receipt# 1 ',�6
Planning & Development Services ,
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982 GC/19
(772)462-1553 CoGr1l,.
SPECIALTY PERMIT APPLICATION
❑ Electricallumbing ❑ IiVAC ❑Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty perndts
1. Location/Site Address: S' adG H 1 ck n ✓� , O y; L c v � A'c -cc � � 3 y gT Z
2. Parcel ID Number: 3 V 0 2 r G 0 S^ 69 0 0- U 0y- 3
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Work: /VQ 0 %-�� G 1^Q
4. Owners Information 5. Contractors Information
Name:
Q d v
AO - e-2
FL Reg/Cert #:
Address:
6606 Jd 1��'
G� Y�/ I
County Cert#:
City:
IQ I C j'C
P State:
Business Name:
0 r-d I L(Z s'& &(Ca
Zip: 13, y l� ), Phone: 2-�3t/�, Phone•-1 iQ& 5-%3%671fiax•
6. Value of Construction: $ l 600. 00
OWNERS AFFIDAVIT: I certify that all of the information containkin thil appl' ation is correct and that all work will be done in
compliance with all applicable laws regulat g con tru ton Ad zoning.
PRINT OWNER OR CONTRACTOR NAME`` SI URE V OWl OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF l lK613C ` rt
ACKNOWLEDG BE DAY OF ` ' 20 I� . BY Ati9AY " '\
IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED
AS IDE TIFICA
� wpy
(seal)
SIG A RE OF ARY TYPE OR P 4my.pwit - StO of FWMs
s 'My Comm. Explm4 in 2, 201i
COMMISSION NUMBER �'., � �a` Commission 41.DD 991843
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF C I M ING 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
�WATER Comm
SEWER
RES
_;METER SZ.
M/F
IRR'
SECURITY DEP
SERVICE FEE
SAME DAY FEE
OVERTIME FEE
0 0 METER INSTALL
CFCAVATER
FPUA CFC
CFC/sEwER
GUAR. REV
LATERAL
�TOTAL
NAME OF SPOUSE
DATE RECEIVED
TILITIES P.O. BOX 728 VT. PIERCE FL 349
C7
ACCT. #
10
Ig lkl /) -2 u- 6 H LC
MOVE IN/CLOSING DATE
This application hereby request and authorizes th,
e Utility to render services to the Premises des ribed above in accordance with jh water and/or sewage disposal
rules and regulations, which c e Utilities present or future rates,
the Utility pro ch by reference are made a part of this contract. Applicant agrees to pay
MPtlY for such services in accordance with the established rules and regulations..
CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANsFERART:p
FED ID
--------------
-------- SPOUSE SOCIAL SEC.
C H PCEaTSE ONLY------
AS CHK #
RECEIVED