HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONFee D,l - Recei t# `�� Permit #
Planning p & Development Services /� / —6 /Oz—
Building & Code Regulations Division
2300 Virginia Ave. S'C`
Fort Pierce, FL 34982
(772)462-1553 �t <Uc's}' FG
SPECIALTY PERMIT APPLICATION C0412
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Electrical ❑ Plumbing ❑ RVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 fojr instructions and additional paperwork required for specialty permits
1. Location/Site Address: 1 `/�` 1 n n
kA-
2. Parcel ID Number: 23 t�S — 1 ZZ - CM2' CW'
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Work: rn v
4. Owners formation5. Contractors Information
Name: (� (���(� �� FL Reg/Cert #:Il�
Address: County Cert#: L�
City: CQ State: Business Name:
Zip: Phone: Phone`- 4lY«J Fax: �2 d `GlQ l —�CDo
6. Value of Construction: $ , d
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 law regulating construction and zoning.
PRINT OWNER ORVONTRACTOR NAM SIGNA E OF OWNER OR CONR
STATE OF FLORIDA, COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF 204a BY - Notar. Public - State o1 C- 9-1.a
onhg Mar 22
Co'"T"tl, 2017
WHO IS PERSONALLY KNOWN TO ME r OR WHO HAS PRODUCED •!''�°F 'PRE Y7!S71
COMMISSION NUMBER
NOTICE TO OWNER: FAILURE TO RECORD A ]
IMPROVEMENTS TO YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
EXEMPT: A/C -HEAT REPLACEMENT WITH CONTRACT UNDER $7500.00
Revised 04/26/2010