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HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONi Date: 1 ;& 1%k lFee Due: 1 r , Receipt# i j 5Z)O 'ermit # Ol -13- _ Planning & Development Services Building & Code Regulations Division 'SCAIWV 2300 Vn ginia Ave. , 13 y 2 [[) • - Fort Pierce, FL 34982 t C1Cj (772)162-1553 e County. SPECIALTY PERMIT APPLICATION ,Electrical ❑ PIumbing ❑ HVAC ❑ Fence ❑ Shed ❑ Demolition ❑ Gas ❑ Siding Seepage 2 for instructions and addition nal papernwor�k[required for specially pernuts 1. Location/Site Address: 31 0 va)) C/T�/'I aI/li/ 2. Parcel ID Number: N 14— 70/' V) 4 1 ` V 00 - 6 Office Use Section Township Range Map Page Zoning Land Use Initials Only 3. Complete Description of Project or Work: A bb 6 1161175 a /U -l0 t,x1.5-rw(hoCK, AI- Q 6F,'f- Fx "DOCK 4. Owners Information 5. Contractors Information Name: 5-F9V60 % SOZAN6 J©kuSTO.V Address: JJ' (� �N C ���� jN,4 C7- City: �r Pr, f�p� State: FL_ Zip: J� 7 l Phone: 79)-87811l71 6. Value of Construction: $ 5,00 OWNERS AFFIDAVIT: I cerhly that all of the Information c compliance with all applicable laws ,,compliance 1 PRINT OWNER OR CONTRACTOR N STATE OF FLORIDA, COUNTY OF �f L, ACKNOWLEDGED BEFORE ME THIS R ./ DAY OF FL Reg/Cert #: 66oci 30- 7,;-) //J(; County Cert#: I l a A Business Name: A(Cop"ff7t ��C(fr Ic&( Gjo l �� Phone: .7R9V `� r 71 Fax: �7'7o�`9 / o oV5 20/ 5 _ correct and that all work will be done in WHO IS PERSONALLY KNOWN TQ MB"/ �J� �R�dL�OHAS PRODUCED e�� O� •••••••••. ��0%i�� VOg�bef?�?'°i AS CATION % � � � - � 9A. L� C. Virgilio = • �� N • aorise _ * _ • (seal): SIG TURE OF NOTARY TYPE OR PRINT NAME OF NOTARY s2 • #FF p48192 Og COMMISSION NUMBER •••��'O�� • Pobfic NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT 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