HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATION"! Permit #
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
• . Fort Pierce, FL 34982
(772)462-1553
(qO5-040D
SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing EHVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for spectalty permits
1. Location/Site Address: 'T L C) 1
2. Parcel ID Number: �s"r p � i ®ooZ ' OM-1
Ki
Va .
Township
Range
Map Page
Zoning
Land Use
Initials
Office Use
Section
Only
4. Owners Inf rmation 5. Contractors Information r r
Name: �Q �,� � _ Q FL Reg/Cert #: L C It `f R ,? -7
0
Address: (4ounty Cert#:
^ r
City:j ln State: Business Name: aAA �lt D 0 /
Zip: Phone: 25 Z9 I V- PonFax: :�Z7 Z O7 7 01
6. Value of Construction: $
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 cons ction a9A zo ing.
,�/ly
PRINT OWNEk OR CONTRACTOR NAME SIGNATURE OFPVNER OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF '5V 6,4 CI'
a
ACKNOWLEDGED BEFORE ME THIS O--O DAY OF 204-1� BY
WHO IS PERSONALLY KNOWN TOME \rOR WHO HAS PRODUCE
AS IpIfNTIFICATION.
siGgAITTRk OF NOTARY TYPE OR PRINT NAME OF NOTARY
$:
l-( -77,5 2
COMMISSION NUMBER
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
vised 04/26/2010