HomeMy WebLinkAboutSUBMITTED PAPERSDate: Fee Due' Recei t# Q4 a 1 Permit #
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bjPlanning Development meat Services y6 -0a�
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Building & Code Regulations Division
2300 Virginia Ave. SC,q
Fort Pierce, FL 34982
(772)462-1553 St B Y
SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing ❑ HVAC Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional papentnork required for specialty permits
1. Location/Site Address: S a o J o 1 e a—.yi rJ e i OL U C
2. Parcel ID Number: ?) off/ -go Q o6 Q b O I
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Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of 'ect or Worl�'�Sr"4."14- C 16 1/ uh 0l G pL L 1�
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mrn an hack oro• ((ho . h "-side back k*m -no v,neJf � 6-F 0ouS
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4. / Contrac Information
Name: Sc' o4 60 Ql yl 04
Address: 5aQ3 1 e 'e.Y fq,
City: R &Eu State: 2F L-
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FL Reg/Cert #:
County Cert#: a3 5 %
Business Name: ih 0'*1 Cp Inc
Zip: 3"( C1 L Phone: 3 --0 0 _W Phone: 3t' U- �?q 7 _Fax:
6. Value of Construction: $ ;tavb ` W—
OWNER's AFFIDAvrr: 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 re ing construction oning.
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PRINT OWNER R NT CTORN-NUE SG OF OWNS AC RR
STATE OF FLORIDA, COUNTY OF
ACKNOWLEDGED BEFORE ME THIS D F � BY
WHO IS PERSONALLY KNOWN TO A OR W'HO HAS PR CED
IDENTI CATION '�
DAWN(la�jNE
SIGNATURE OF NOTARY TYPE OR PRINT NAME OF NOT Y=o`* *<<'; Notary Public -State of Florida
COMMISSIONNUMBER N. * Q My Comm. Expires Mar 22, 2017
"P o,� commission # EE 877571
of F,_ o A.n 7hm mh National Notary Assn.
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT h Y R
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND T T N F ANCING, 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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