PERMIT DOCUMENTS Jan 24 2017 12:12PM Onsite Electrical Service 954-368-4654 page 1
UNIVERSAL COUNTY-WIDE/MUNICIPAL FOR OFFrCEUSE ONLY
BUILDING PERMIT APPLICATION FORM PBC Version: Permit Type:
July 201.3 Edition Accepted By: Application Date:
Approved for use throughout Palm Beach County and Municipalities Application r:
1 a
KIND of PERMIT(CHECK ONE): PROPERTY OWNER:Wales Management Inc of Flame
o PRIMARY PERMIT TENANT:Some
IL SUB-PERMIT-If Fee&Value of a Sub-Permit are ADDRESS: PO Box 1450 UNIT:
covered under a Primary Permit complete boxes L,3 4.5.6 §L
I only to apply.if not covered under a Primary Permit, CITY: Chicago STATE: LL ZIP:60690
complete the entire application to apply. PHONE: 864-884-2028 FAX:
EMAIL: !odd$wracam
I 5 -
TRADE (CHECK ONE): PROJECT NAME: Waste Management Boynton BeachhCNG Fueong System Expanelm
❑ STRUCTURAL o ROOFING o ELECTRICAL pay: 08 . 43 _ 45 - 16 . 25 .000 -0160
o MECHANICAL I PLUMBING ❑FIRE ❑GAS
o OTHER: LEGAL DESCRIPTION:See lnladted lalrvey
PRIMARY PERMIT ft: In-SG 3g ADDRESS: 651 Industrial Way
CITY: Boynton Beech,FL
a
FURTHER WORK DESCRIPTION: hsteoeticn of stainless steel pipirg as par plan
Type of Work: o New o Addition B Alteration ❑Repair o Demo o Temporary o Other
VALUE: PERMIT FEE: NET S.F(for SFD's): MA
(STE FEESOIEptLI (AS ORM) (ASAWn E51
a
O OWNER BUILDER PER FL ST,482(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2)
I CONTRACTOR(CERT.HOLDER): Scott Thomason License of: CFC1427522
DBA(COMPANY NAME): TH Building Gmup LW Contact Person: Scot Thornssm
ADDRESS: 877 SW Roberts Ave STE:_CITY: Fen Wale STATE: FL ZIP:32038
PHONE: 15-D587 FAX: 6386-315-0587 EMAIL emllGlhonesona email mm
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 prior to the Issuance of a permit and that all work will be performed to meet the 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 the foregoing information Is accurate and that all work will be done in compliance
with all applicable laws regulating construction and zoning.
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1p-mmrn ererMeml fneludingeontranrl Dianne°faEmessr Meed llndudleg centrally)
print Name: hr pt + t_vrny 6mr1 Print Name:
NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/ NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/
BUILDERS REGARDLESS OF$VALUE STATE OF FLORIDA BUILDERS REGARDLESS OF$VALUE STATE OF FLORIDA
COUNTY OF'1 ifr anrcI COUNTY OF
Sworn to(or affirmed)and subscribed before me this MAI Sworn to(or affirmed)and subscribed before me this
day of .*n.n,.,c..a ur.- ,_11:2_11_,by day of 20 ,by
tt Q — " `uBrN4SOrt
NW*el pew making Mimed) (Rams at Innen Ming eatma4
(Signature of Notary Public-State of Florida) (Signature of Notary Public-State of Florida)
(Print,Type,or Stamp Commissioned Name of Notary Public) (Print,Type,or Stamp Commissioned Name of Notary Public)
Personally Known OR Produced Identification_ Personally Known_OR Produced Identification
Type of identification Produced Type of identification Produced
; '*y, CATHLEEN A ROUSE Page 1.of 2
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