HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATION08/05/2013 10:46 561-49''7�1 ECM PAGE 02
Date: 14ee Due: Recei t# ' Permit # _
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave. `SIC,q
FortPierce, FL 34982
(772)462-1553
C
SPECIALTY PERMIT APPLICATION
Electrical U 'Pluinbing ❑ HVAC_ 0 Fence
11. Shed �E Demolition ❑ Gas ❑ Siding
Seepage 2 firr instracdons and additional paperwork required,for specialty pernrils
i. Location/Site Address:
2. Parcel ID Number:
affir e rise
Only
Feation
Townehlp
Range
Map. Page
Zoning
Land Use
Ini(lais
3. Complete Description of Project or Work:
4. Owners Information 5. Coritractors Information
Name:
Address: ��•�j, _ -
City: tt��'f �Llr 'I�state: T�
Zip: C7 Phone:`
6. Value of Construction: S Z ' 03
Compliance with all applicable laws
WHO IS PERSONALLY KNOWN TO ME ►i OR WHO HAS
FL Reg/Cert #: Ec1oo Lsa
County Cert#: �;t `
Business Name: fil_.uISrhlY1lCw-
I -►P(31! Phone. � Fax:
NOTARY PUeI.lC
_ (Real)
B_ fURE O�OTARY TYPE OR PRINT NAME OF — ' ATE w_ F FLOP
(X)MMISSION NUMBER ..... Expfts 417 M16
NOTICLTOQWNTR: FAIII.URG 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
LE iVIDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. -
EXEMP"is A C-HEAT REPLACEMENT wrrH CONTRACT UNDER $7500.00
Revived (1442612010