HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATION_z
Date: Q, 1'31 J Lj Fee Due: K �- _ ,' O IReceipt# zit # Ilia — Q X 1 D
Planning & Development Services
Building & Code Regulations Division
n 2300 Virginia Ave. S
Fort Pierce, FL 34982 C,l/'V
(772)462-1553 �t Q y�FCj
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SPECIALTY PERMIT APPLICATION 04#6,
❑ Electrical ❑ Plumbing E/HVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required forspeclalty permits
1. Location/Site Address: NIM A 1�14 NO
2. Parcel ID Number:
Office Use
Only
Section
Township
Range
Map Page
2;oniag
Land Use
Initials
3. Complete Description of Project or Work:
J 1 _
Jr K 0 `vy DlIrIt. / fCsee. f
4. Owners Information n ,�nn 5. Contractors Information
Name • ,�Di�( &W w �L G(J��A7) FL Reg/Cert #: C Ki C O $ t 81 D
Address: �12a0 /U X 14 1110
City: C426!�2� State: L
Zip: Phone:
6. Value of Construction: 5L�%
County Cert#: 277 4
Business Name: 645?eM Alt 94S T£ ril S 1 rJ C
Phone:77a 33S 313a Fag: 77A 93S 1168'
oWNER,s AFF nAvrr: I certify that all of the information contained in this application is correct and that all work will be done in
compliance with all applicable laws regulating n an oning.
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PRINT OWNER OR CONTRACTOR NAME SIGNA OWNER OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF 5r L U m a'
ACKNOWLEDGED BEFORE ME THIS /d DAY OF / -Lei , 20//. BY gu'?TkS `-' l�tnlnO/Us
WHO IS PERSONALLY KNOWN TO ME V1 OR WHO HAS PRODUCED
�p0.Y PV
r°.; •'•.;�% CHRISTINE B. ENGUSH
AS IDENTIFICATION.
* * se
-e MY COMMISSION # EE 859284
, & r r/ (seRPIRES: April 4, 2017017
SIGNATURE OF N ARY TYPE OR PRINT NAME OF NOTARY EOF fid�4 Bended Thru Budget Notary SeMcsn
COMNIISSIONNUMHER
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