HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONDate: ee aui i-=_1 Receipt# .i PernAt # Q�
Planning & Development Services SCq
Building & Code Regulations Division
2300 Virginia Ave. �� CO
Fort Pierce, FL 34982
(772)462-1553 41,
SPECIALTY PERMIT APPLICATION
® Electrical 0 Plumbing M'1VAC ® Fence
® Shed 13 Demolition 0 Gas ® Siding
Seepage 2 for instructions and additional paperwork required forspeciahy permits
t. Location/Site Addre
2. Parcel ID Number:
Township
Range
Map Page
Zoning
Land Use
Initials
Only
3. C
4. Owners formation 5. Contractors Information
Name: Cs3 1�Q_ FL Reg/Cert #.-
Address: fCASS County Cert#:
- ` ��n
City: Q�N` State: Business Name:
Zip: -Z`t� l Phone: '§40 ""'4 Phone: , t0 4.04am
C. Value of Construction: S
OWI'VER'S AFFIDAVIT; I certiA, that all of the information contained in this application is correct and that all �%—ur—kzvdll be done in
compliance with all applicable la«.-s regulating co pon onmg.
PRINTOVVNERORC011TRACTORKs—ME y SIGN:\ OFOWty RURCON1ttACTOR
STATE OF FLORID:1 COUVTI' OT e � ( jC 4P
ACQKORIEDGED BEFORE 4� TIIS �DAY OF P0 ^ �vl
2
R'HOISPLRSOVA17.NONVi\l'r0_�,I t-411 llHO HAS PRODUCED
AS ENTIRCATIOA.
(seat)
IGNA'n F NOTARY TYPEQP��TNMINII'A�11��((
COAE1-IISSION \TI.?VIBER rr
NUI'ICETOOWNER. FAILURE TO RECORD A NOTICE OF COMMENCENMI?.NT MAN RESL7.T iN YOL°R PAYING TWICE. FOR
IMPROVENWNNI'S TO YOUR PROPERTY. IF YOU; INTEAM TO OBTAIN FINANCING, CONSULT 11ITH YOUR
LEYD172 OR AN, ATTORNEY BEFORE RECORDING YOUR NOTICE OF C:ONINj 1�CT<'4IE:\T.
EXENIPT: A/C -HEAT REPI.ACEIIME;NT WITH CONTRACT UNDFdt" _ � � � —
Rerised 04n6C010
nO,a� JERALYNNE RUSSELL
i Notary Public - State of Florida
My Comm. Expires Jul 22, 2017
j�OF FIOP�� Commission # FF 038392
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