HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATION05/30/2014 15:44 FAX ;_y fJ001/002
Date: i Fee Due: Co Recei t# . Permit # j d Ob0
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave. 8 FQ
Fort Pierce, FL 34982 St ( Y
(772)462-1553 UCie CpUnty
SPECIALTY PERMIT APPLICATION
❑ Electrical ttlumbing ❑ RvAC ❑ Fence
❑ Shed ❑ Demolition ❑• Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: 3;2 `7 5 C %VA r4 h�a 4 U f_ PS L 3 U-9 S 3
2. Parcel ID Number: 34 0 - 5E30 - cola-mo - fo_
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Rork:
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4. Owners Information 5. Contractors Information
Name: '� ��, 1 V a.w1,e...1 FL Reg/Cert #:
Address: a County Cert#:
City:
Zip:
State:
Business Name:
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s
Phone: -77a —M -11�]
6. Value of Construction: $ /j !
OWNER-S AFFIDAVIT: I certify that all of the information contained in
t compliancewith all applicable laws regula
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PRINT OWNER OR CONTRACTOR NAME'
STATE OF FLORIDA, COUNTY OF '/
ACKNOWLEDGED BEFORE ME THIS DAY OF Q 20 / _ . BY
WHO IS PERSONALLY KNOWN TOME �OR WHO HAS PR CED /
and that all work will be done
ASI TIFICATION- nn nn l rah` rp'`t+: RHONDA LAFFERTY
%%� 1&nnd. LG.T [J J Li '�k' ": Ir9Yal;OMMISSION # EE854297
SIGNATURE OF NOTARYU U TYPE OR PRINT NAME OF NOTAY ;,? EXPIRES January 08. 2017
�� • 4 (d07) 398.0153 FbndallotarySer ice.rom -
COMMISSION NUMBER /
r
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: AIC-HEAT REPLACEMENT WITH CONTRACT UNDER S7500.00
Revised 04/26/2010