HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONPlanning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
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SPECIALTY PERMIT APPLICATION
❑ Electrical Plumbing ❑ HVAC ❑ Fence
❑ Shed ❑ Demolition ❑' Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: Q 40
2. Parcel IDNumber: I` *k01 -1; 3() -0�` 4- 000. -�
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Work:
4. Owners Information 5. Contractors Information
Name: W-,/;n 'ir '�10r C . Co l'O_
Address: jsi., NAr01/1y
City: P A St . �t✓�� State:
Zip: Phone:
6. Value of Construction: $ � -� 01 Ot
FL Reg/Cert #: cy—c'\ 4-�' �&()
County Cert#: 3�j p
Business Name:at,;,nF�A���;n
Phone:1114J t-qyA Fax:]11-v 1-goo
AFFIDAvrr: I certify that all of the information contained in this
compliance with all applicable laws regulatiggcons
PRINT OWNER OCONTRACTOR NAME SI NA O OV
i
STATE OF FLORIDA, COUNTY OF. r'
ACKNOWLEDGED BEFORE ME THIS Lsli— DAY OF 20�, BY
WHO IS PERSONALLY KNOWN TO ME A_ OR WHO HAS PRO UCED
will be done in
AS IqljNTIFICATION.
�q*•°U RHONDA LAFFERTY
Mys oMMISSION # EE854297
SIGNATURE OF NOTAR E OR PRINT NAME OF NO ARY =. EXPIRES January 08, 2017
COMMISSION NUMBER y bJ �✓ ` r (S07) 398.0153 �IaidallolorySery ce.com
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
ZOO/TOO 0 %Vd TO:OT PTOZ/SZ/50