HomeMy WebLinkAboutBuilding Permit Application Date: ' Fee Due: Recei t# Permit# — d
Planning& Development Services
Building&Code Regulations Division
2300 Virginia Ave.
Fort Pierce,FL 34982
(772)462-1553
SPECIALTY PERMIT APPLICATI01
❑ Electrical ❑ Plumbing HVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
See page 2 forriz
instructions and additional paperwork required for specialty permits
1. Location/Site Address: C> (oq (V\�K
2. Parcel ID Number:
Township Range Map Page Zoning Land Use Initials
Only
3. Complete Description of Project or Work: -� l
2 -S 4C)V1 1 L-V
4. Owners Information 5. Contractors Information l
Name: (�, _ V Q FL Reg/Cert#:
Address: '�pAV �-}�. 1���/1 �/ County Cert#:
City: \\ 11-1Q V.��� State: Business Name: �/ 1�,( t(n -Q Ino—
Zip: 1�, (O-L(p Phone:
6. Value of Construction:$
OWNER'S AFFIDAVIT: I certify that all of the information contained' this application is correct and that all work will be done in
compliance with all applicable laws regula' cons ctio d zoning.
PRINT OWNER OR CONTRACTOR NAME N F OVINMR OR CONTRACTOR
STATE OF FLORIDA,COUNTY OF —J* `
ACKNOWLEDGED BEFORE ME THIS DAY OF '� 20 S.BYV 1_
zID
ISPERSONALLY OWNTOME�OR WHO HAS PRODUCED
ENTIFICATIO
A.VLA I (seal)
SIGN TURE OF NO t
ARY TYPE OR PRINT NAME OF NOTAR
COMMISSION NUMBER V r:� 1
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
Jamie Peme
Revised 04/26/2010 NOTARY PUBLIC
STATE OF FLORIDA (� S
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