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Date: l• - Fee Due: Recei t# I Permit# (60 (o -
Planning
Q -Planning & Development Services
7 J I w °t Building & Code Regulations Division RECEIVED
2300 Virginia Ave.
• , Fort Pierce,FL 34982
(772)462-1553 JUN / 8 2016
SPECIALTY PERMIT APPLICATION
❑ Electrical :Plumbing ❑ HVAC ❑ Fence
❑ Shed ❑Memolition ❑ Gas ❑ Siding
Seepage 2 for insttrrucdons and additional[p)aperwork required for specialty permits
1. Locatio Site Address:
2. Parcel IDNumber: .��o�
Township Range Map Page Zoning Land Use Initials
Office Use Section
Only
3. Complete Description onProject or Work: ZIV5z- P954/15ee- f170i/L=
19 A/C
us"X' w n o is?4C e7 - gELAC-aTi 0 -e i r-� r alb
rev 0VL: C �a L• r 4 , , .
4. O'�ners Information 5. Contractors Informati
Name: FL IZf�L�f�2L� /� J FL Reg/Cert
Address:
(kv Smv-110 A�Qi County Cert#:
J
City: State: j L Business Name:
y 33q
Zip: 1 S Phone: 7 3Z3� Phone:_yG�_ �% ��
6. Value of Construction: 1.
OWNER'S AFFIDAVIT: I certify that all of the information contained in this application is correct and that all work will be done in
compliance with all applicable laws regulating constru n and zoning.
PRINT OWNER OR CONTRACTOR NAME SIGNATURE OF ER OR CONTRACTOR
STATE OF FLORIDA,COUNTY OF�
ACKNOWLEDGED BEFORE ME TIIIS_ DAY OF - 20� J BY E
WHO IS PERSONALL TO ME OR O HAS PRODUCED _
ASIDENTIFIOATI ,�pan�pg4 ANDREE GMEENE
•'�� Notary Public State of Florida'
(seal)
SIGNATURE F Y T OTpgy
My coni'' pueS W 31,2020
;..
COMMISSION UMBER �''fa R�`� ! 9j
}
„►� Bonded t .0 va„vr:al Notary Assn. ,.
NOTICE TO O ER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
i 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)rC-HEAT REPLACEMENT WITH CONTRACT UNDER$7500.00
Revised 04/26/2010 F'