HomeMy WebLinkAboutSUBMITTED PAPERSDate:
Due:
1-1
Permit #
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave. �Q1/V/V fD
Fort Pierce, FL 34982 IS &
(772)462-1553 RUCie COU
sty
SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing
❑ Shed ❑ Demolition
Seepage 2 for instructions and
1. Location/Site Address:
❑ HVAC Fence
❑ Gas P13 Siding
itional papenvork required fgrr specialty permits
_10 /1/1 1 r' bl pf-vc'12 e0a
2. Parcel ID Number: (� pS L`JL� Cl / " no ^ U
Office
Only
Section
Township
Range
Ma Page
ning
Land 'se
Initials
3. Complete Description of Project or Work: 6 5qL,-t-a,(( . A f Gt_ M t �
Cep. c e (-,) i"Q - t -, el '' `2 �,,C.k-e - - s , a a a-k--e_S
4. Owners Inforration 1 05. Contractors Information
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Name: %-� I % i �Q .1/L FL Reg/Cert #:
Address: �V f� County Cert#:
City: State: Lcj` Business Name:1'G��T
Zip: 31 Phone: 3l �p �OrP— I Phone: / /0� `-I"�' �4 ax: / 7 o� - ` VE 3Q 5 Z�—
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6. Value of Construction: $ ���•
Ow\'ER'S AFFIDAY'IT: I certify that all of the information contained ' its application is correct and that all work will be done in
compliance with all applicable laws re ating co stniCtion and oning.
c G�lIL�S r-��'V�-V�
PRIN71OWNER. OR CONTRACTOR NAME 9rG-.\TA7tJRF OF OWNER ORCCONTRACTOR.
STATE OF FLORIDA_ COUNTY OF
ACKNOWLEDGED BEFORE ME THIS 0 DAY OF 20 �. BY
WHO IS PERSONALLY C�N I ME)& OR WHO HAS PRODUCED
AS IDENT ATS
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p ` "� ferry S Grimot �sra;
GI\ URE OF C TYPE OR PRINT NA OF NOTARY c Qa My Commission f]D993307
COMMISSION N :1BER2Z c'J30� ''ref moo- xPiresOb/18/2014
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEINfENT MAY RESULT LN YOUR PAYING TIVATCE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT NNUM YOUR
LENDER OR NUN ATTORNEY BEFORE RECORDING YOUR tiOTICE OF COMMENCEMENT.
EXEMPT: A/C -HEAT REPLACEMENT ti'ITH CONTRACT UNDER $7500.00
Revised 04/26/2010
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