HomeMy WebLinkAbout2555 Park Ave (2)Historic District:
Zoning:
Value of Work:
..ate
Permit Type: Building Electrical Mechanical Plumbing Fire Sprinkler/Alarm Pool.
Electrical: New Service — # of AMPS Addition/Alteration Change of Service Temporary Pole
Mechanical: Residential Non-Residentialy Replacement (// New (Duct Layout & Energy Ca1F. Required)
Plumbing/ New Commercial: # of Fixtures # of Water & Sewer Lines # of Gas Lines
Plumbing/New Residential: # of Water Closets Plumbing Repair— Residential or Commercial
Occupancy Type: Residential Commercial Industrial Total Square Footage:
Construction Tyne: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required foir other than X)
Parcel #:
(Attach Proof of Ownership & Legal Description)
Owners Name & Address: ,"i-, kGei cc GLS X !� �^
!') —. Phone: �Q1 IA, -)^c; 77 -
Contractor Name &'Address: `2-� 11 -PV C—A-C - d
y 4JA ` ' `� 4 / State License Number:
Phone & Fax: '-&W-0S5 «Contact Person: /ia.3f J4 Phone: 5X0 -3,x.3; 3VP
Bonding Company:
Address:
Mortgage Lender:
Address:
Architect/Engineer: Phone:
Address: Fax:
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced poor to the
issuance of a permit and that all work will be performed to meet standards of all laws regulating construction in this jurisdiction. I understand that a separate
permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, and
AIR CONDITIONERS, etc.
OWNER'S AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constriction and zoning. WARNING TO OWNER YOUR 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.
NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of
this county, and there may be additional permits required from other governmental entities such as water management distri ts, state agencies, or federal agencies.
Acceptance of permit is verification that I will notify the owner of the property of the require ents of Florida Lien Law, F 713.
l 5 c�3
Signature of Owner/Agent Date Signature of Contractor/Agent 17'�Sl
Date
e- /f�
Print Owner/Agent's Name
Signature of Notary -State of Florida Date
0%vner/Agent is Personall\ Known to iVle or
Produced ID
,%PPLI( Al ION APPROVED BY: Bldg: Zoning:
I Initial & Date)
Special Conditions:
ContractorAgent's Na e
S azure of N`1)* Sta-ti of l'IMM �1MISSION # C0192I Q8
ij �t
` E IRES: March 23 2-604
pli
�9 orr± d udget Notary 5_?
Contractor/Ager.: is Pcrsonali.v Known to Me or
ProduceC :D
(Initial & Date)
FD:
(Initial K Date) (InHtial & Dat;