HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONDate: 31 1411 H 1 Fee Due:
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Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing 0 HVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
See page 2 foorr instructions and additional paperwork required for specialty permits
1. Location/Site Address: " ! 9/C� �a/ t^/l� CiY' le
2. Parcel ID Number: /l /;� - Q0 ! - Di Qa - oc7
3.
Ofjice Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
Description of Project or Work: 1-ke 4r
<�W = Itom Pw -
4. Owners information / 5. Contractors Information
Name: -Ta FL RegtCert #:
Address: paler') County Cert#: (�•� /
City: V" . State: Business Name: �4A ffi('L:410n:n�
Zip: �'�\ Phone: i7,)- 160-LQQC) Phone: 77ay61-MC Fax: i'�2"y61
6. Value of Construction: $
OWNER'S AFFIDAvrr: I certify that all of the information contained in thiFc
lication is correct and that all work will be done in
compliance with all applicable laws regulatin tZ;ONTRACTOR
ing.
y— lM r
PRINT 0 OR CONTRACTOR NAME SIGNAT OF
STATE OF FLORIDA, COUNTY OF 5 N, L V C. i k
ACKNOWLEDGED BEFORE ME THIS DAY OF 'M Ch 120 1 . BY St•e v, S w�NA %N
WHO IS PERSONALLY KNOWN TO ME O HAS PRODUCED
`�' �''. DEANNA GIVENS
S IDENTIFICATION. °+ *`CI? Notary Public - late of Florida
016
D PL4 q\hq G V t VN »• My Comm. E Dec 1
SIGNATURE OF NOT TYPE OR PRINT NAME OF NOT �F° °p��' Commission 016
* ti, I
4 0.
c BI& Bonded Through National 850i81
COM ESSIONNUMBER G0sO01 CP 1 Msn.
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 S7500.00
Revised 04/26/2010