HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONFee Due:
--1 Permit #
•F iL Ci iA' :Q _ 3?•• ih
❑ Electrical
❑ Shed,
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION
af Plumbing
❑ Demolition
❑ HVAC ❑ Fence
❑ Gas ❑ Siding
See page 2 for insttrrre ions and additional papenvork requiired for specialti? permits
1_ 'Location/Site Address: 10? �� a%l a V�
2. Parcel ID Number: 3 `- 1 q -,5 -/0 - Q 3 q1-
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3. Complete Descri
4.
of Project or
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Wa�er hea�fr
Owners Informs - n 5. Contractors Information
Name: C 60 1c hcl "
Address: 0 t� /0b7r! A V
City: State:
Zip: ��021v Phone:
Do 'lane
6. Value of Construction: S d D
FL Reg/Cert r:
e
CFC 0580a5
County Cert*: / q 7,3 9
Business Name: PC) ��C'te RU2
1 Ct
Phone: "652 Fax: q g ! - / l z to
O«FIER'S AFFIDAVIT: I certit'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.
GarV W , G.cl ne 110 s
PRINT OWNER OR CONTRACTOR NAME SIGNATURE OF OWNER OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF ,Sf L u`C I
ACKNOWLEDGED BEFORE YtETHIS 45�,l Al`OF G t° 10 / BYE
WHO IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED $A """ anielle Biglin
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S?. = COMMISSION # EE 107315
AS t TIFICATI �:P EXPIRES: AUG.25,2015
�)'J i G e +1iC{ 3 ''•.�`,,°N�;;°•° OAWAARONNOTARY,com
SIGNATURE OF NOTARY TYPE OR PRINT NAME OF NOTARY
COivilMISSION NUMBER L - 10 73 15
NorrICETO O«1NER: FAILURE TO RECORD A NOTICE OF CONINIENCEMENT MAY RESULT IN YOUR PAYING Ttil'ICE FOR
IVIPROVEMENIS TO YOUR PROPERTY- IF YOU INTEND TO OBTAIN FINAaNCLNG, CONSULT'Vl'ITH YOUR
LENDER OR AIN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMINIENCEME N'T.
EXENIPT: A/C -HEAT REPLACEMENT WITH CONTR:1CT UNDER S7500.00
Revised 04R62010