HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONpia rAF
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553 Fax 462-1578
SPECIALTY PPRTVM APPLICATION
❑ Electrical ❑ Plumbing 19 HVAC ❑ Pence
❑ Shed* ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/SiteAddress: I'll MG Mai?— 1NiR AMS
Z. Parcel ID Number: Ll 1 R 5 30 ' b �� L b Gs O
S Sc/VyvEI)
e
t. Y
4C%@ County
3. Complete Description of Project or Work: G C HA.��� �u7 G. e.ka.
1>cA G 20 G r-A FXML1x 3&%>
4. Owners Information 5. Contractors Information
Name: C)on S e`tta fn 75 M s� yc FL ReWCert #: eA Co SP6 &d
Address: $ L Mrs MARg 1`i J.F� J-D►yA
City. X"m' ; State: IFL
County Cert#:
Husiness Name: C4eAj-e Aei- �EeH e�at_n$e4 S
Zip: S. keq%3 Phone: 14;L- 03$a- pllone:'315'-4Lo61 Fax:
6. Value of Construction; $ -31 so
CA
OWNER'S AFFIDAVIT: 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 regulating construction and zoning.
�EE !.tee L-A-A
PRINT OWNER OR CONTRACTOR NAME
STATE 017 FLORIDA. COUNTY OF
PSWrOWOF OWNER OR CONTRACTOR
ACKMOWLEDGED BEFORE ME THIS Aq DAY OF 1"A V 20_jq _., BY : t-C-4C A 4+M a NbA
WHO 19 PMSONALLY KNOWN TO UZ Z OR WHO HAS PRODUCRb
AS Ii7ENTIFICATION.
{ } Rag G.� a �► r L = SA DRA WALSM
;-=���•' — F� • ••--- - ' �"I MY•�M!$$IOIVdItFF0911)d
SIGNATURE OF NOTARY TYPE OR PRINT NAME OF NOTARY '�.,, Nly. 3ES April 11. 2Ot a
COMMISSION N=3RR
*ALL ,RESIDENTIAL AND NONRESIDFNTLA-L STRUCTURES ARE REQURIED TO MEET THE FLOOD ZONE
ELEVATION OR 18 INCITES ABOVE THE CROWN OF THE ROAD, WMCDE'VER IS APPLICABLE. (see instructions on
reverse side of this sheet)
Revised 03/18/2014
08 H £000/£000d £LO-1 -WOad £z=60 VLF 6Z-90