HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONDue:
Permit #
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATION.
electrical
❑ Plumlbing
❑ HVAC
❑ Fence
❑ Shed
❑ Demolition
❑ Gas
❑ Siding
See page 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: a d /0 J., i 0 i; c hwa & Pof- F s 1'tyui (�- L 3 q9 s-c/
2. Parcel ID Number:
Office Use
Only
Section
Township
Range
Map Page
Zonin
Land Use
nr-
Initi s
3. Complete
40i is
of Project or Work:
skr'
c
u
4. Owners Information rr rr 5. Contractors Information
Name: SAIVl�S. �(��� Sdiy �t�� FL Reg/Cert#: �^ C O� 2 7 6 t7
Address: ► '0(® Rwei'6i% County Cert#: cp��? tin
City: •` ICsl=t S`r LItC:i a State: Fr L Business Name: �C� o (L L�e �1 1` I G c� ,�G� � � y- � n t
Zip: ��� �S�I Phone: "7��-� 3� o',j Phone: F 00 3 *�'f6Fax: 777- 600 67-6 3
6. Value of Construction: S�
OWNER'S AFFIDAVIT: I certify that all of the information contained in this application is correct and that all work will be done n
compliance with all applicable laws reguk,t' g construction an zoning.
—i0.w1-PS n 10 5
PRINT OWNER OR CONTRACTOR JqAME S114NATURE OF O R OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF MA1�i t it1 n p� l
ACKNOWLEDGED BEFORE ME THIS 2-q-rit DAY OF M A 20 )3 . BY )Tc— eS �1 1 11i I � I I� S
WHO IS PERSONALLY KNOWN TO ME_�/OR WHO HAS PRODUCED
AS IDENTIFICATION.
Haccarei-q.Ul� UfJ;ti� PyI �� GARETJ. SION # DD 8975710N
SIGNAWRE OF N ARY TYPE ORoPRINT NAME OF NOTARY EXPIRES: June 17, 2013
t-� Bonded Thru Notary Public Underwriters
COMMISSION NUMBER D•D 697 5 !'
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 WITII CONTRACT UNDER $7500.00
Revised 04/26/2010