HomeMy WebLinkAboutSPECIAL PERMIT APPLICATIONDate:
Fee Du
_ . '' Permit #
Uhl. Electrical
❑ Shed
i L7 /0�`
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
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SPECIALTY PERMIT APPLICATION
❑ Plumbing ❑ HVAC ❑ Fence
❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperw,ork required for specialty permits
1. Location/Site Address: ?U�-) &'J,�r� (T I erye
2. Parcel ID Number: N: J- - [oo I - Co (5 - D to - G
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Work: �n(akA- 61160f WP;'a(CA-VI
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4. Own e nformation 5. Contractors Information
Na1k 1 ►yY 11V (A C8-S xbS1d 1 FL Reg/Cert #: me: 1 �
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Address: J \% C2—kl(6ffi lA ��'B County Cert#: 2-0662,
City: �f� • State: Aq Business Name:
Zip: Phone: 3L4�- ���p� Phone• l'o� Fax l l�� I- `�s4s
6. Value of Construction: 5v - v
OWNER'S AFFIDAVIT: 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 construction and zoning.
PRINT OWNER OR CONTRACTOR NAML, SIGN O NER OR COWIZACTOR
STATE OF FLORIDA, COUNTY OF n _
ACKNOWLEDGED BEFORE ME THIS QI/) 0AY OF
WHO IS PERSONALLY KNOWN TO ME — OR WHO I-114S PRODUCED
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ASb NTIFICATION.
Lt-e—
ATURE OF NOTARY
COMMISSION NUMBER
200/0�6/ BY
DAWN MILDNE ��
u Notary public
9 ; = M State of Florida
Y Comm. Expire,,
Mar 22, 2017
'•;o��CEE
PRINT NAME OF Y Bonded ission #877571
Throuoh National Notary Assn
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
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