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HomeMy WebLinkAboutSPECIALTY PERMIT APPLICATIONI Date:'i13 0 U'?, 1.Fee Due:'i-1, dy Receipt# J Q Permit # 1361 y 0 0 Planning & Development Services Building & Code Regulations Division `SC 2300 Virginia Ave: q • Fort Pierce; FL 34982 (772)462-1553 4Cie C q/,� SPEC.ULTY.PERMIT APPLICATION lectrical ❑ Plumbing ❑ HVAC ❑ Fence [3- Shed ❑ Demolition ❑ Gas ❑ Siding Seepage 2 for instructions and additional paperwork required for specially permits 1. Location/Site Address: 2. Parcel iD Number: Q I — 60 s — ®ci S — — Of,Sce Use Only Section Township Range Map Page Zoning Land Use Initials 3. Complete Description of Project or Work: 11�e /a ce 1-7efe /F Ga -, , GIS 1pt-,in .2 ,,f,l,t,e5 fr-i'L) S,.,,1-c4 iiw-+ ove.-AewJ eidi/'d%/ 44. Owners Information 5. Contractors Information Name: "R©be r i- i FL Reg/Cert#: L`- non n Icy L 3 r-� U Address: I io Q I -DDr) n County Cert#: ! Tf to y City: Fo C' i- j?I e f c Q- State: - Business Name: cl tno r, C I e C f (1 C Zip: C[S ( Phone: 771-332 - lSa9 Phone: IFax: �ol 907 6. Value of ConstructioS o� fJ n: OWNERIS AFFIDAVIT: I certify that all ofthe information contained in this application is correct and that all work will be done in � 1 compliance with all applicable laws regulating construction and zoning. % / l �r� S�oIPK r W ��CI1r,o•,d � 1,V PRINT OWNER OR ONTRACTORNAME SIGNATURE Of OWNER OR CONTRACTOR STATE OF FLORIDA, COUNTY OF C—A- • L Nc , Q ACKNOWLEDGED BEFORE ME THIS 30t r DAY OF to tAPi- 20 13 BY . C h r ; S+o ah er• t-,) R , C h 1-1 0 WHO IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED AS •NTIFICATION. CASEY 131NkLEY SIGNATURE CW NOTARY TYPE OR PRUVNANE OFNOTARY - MY COSSION # EE117856 EXPIRES August 16, 2015 COMMISSIONNUMBER C I ?ost(,.• „�„ (407) 398-0153 Flo:idalloteryService.com 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 $1500.00 Revised O 2612010