HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONDate: 5 a 11, n I Fee Due: ',1 i"j Receipt#- -a4- 5 A- _'ermit # ' V3dS �707 01
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort,Pierce, FL 34982
(772)462-1553 St.
SPECIALTY PERMIT APPLICATION
Electrical ❑ Plumbing ❑ HVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
See page 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: 32�00 6\) � I R
2. Parcel ID Number: I `1`�A,- ZZO - ODD � ^ COD -
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3. Complete Description of Project or Work:j'1S-
4. Owners Informationn 5. Contractors Information 2 2
Name: �1(" T ��I(ljl� ` �.Q��(,( FL Reg/Cert #: ( 'Jn6
Address: �0:) ar0YYbVJ g)ea_ V County Cert#: Zb 20Z
� f
City: State: \ . Business Name:M"tL-f`t G
Zip: ��z3g9 Phone: 1- 2�j5 I Phon@:IC. �-t -� ax:
6. Value of Construction: $ a O
OWNERS AFFIDAVIT: I certify that all of the information contained in this application is correct and that all work will be done in
compliance�a)k with all applicable laws regulating construction and zoning
mt�
NVOWNER CONTRACTOR NAME SIGNAT F OWNER OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF 6>f • LV
ACKNOWLEDGED BEFORE ME THIS a�� DAY OF ��y 20 �3 BY �d YVN
WHO IS PERSONALLY KNOWN TO ME OR O �PROQ9-1'bt 1M 3 LkO - 4 4 DEANNA GIVENS
Notary Public - State of Florida
AS IDENTIFICATION. s. ; • My Comm. Expires Dec 16, 2016
=� Commission #t EE 858761
SIGNATURE OF NOT , Y TYPE OR PRINT NAME OF NOTARY illt`•• Banded Thr)lational Notary Assn.
COMMISSION NUMBER E1:4S' 1 4 t
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 WITH CONTRACT UNDER $7500.00
Revised 04/26/2010