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PERMIT DOCUMENTS UNIVERSAL COUNTY-WIDE/MUNICIPAL FOR OFFICE USE ONLY BUILDING PERMIT APPLICATION FORM FBC Version: Permit Type: July 2013 Edition Accepted By: Application Date: Application#: Approved for use throughout Palm Beach County and Municipalities KIND of PERMIT(CHECK ONE): PROPERTY OWNER:Stacey R Chinn and/or Michael Grant ['PRIMARY PERMIT TENANT: ❑✓ SUB-PERMIT-If Fee&Value of a Sub-Permit are covered under a ADDRESS: 3565 South Lake Drive UNIT:_ Primary Permit,complete boxes 1,1,4.5.68}8 only to apply.If not BoyntonSTATE: ZIP: covered under a Primary Permit,complete the entire application to CITY: Yn Beach FL 33435 applY. PHONE: FAX: EMAIL: 3 If TRADE(CHECK ONE): PROJECT NAME: ❑STRUCTURAL DR00FING ❑ELECTRICAL PCN: 0 8.4 3.4 6. 0 5. 0 4. 0 0 3. 0 1 0 0 0 MECHANICAL ['PLUMBING ❑FIRE ❑GAS ❑ OTHER: LEGAL DESCRIPTION:LAKE EDEN PL NO 2 LT 10 BLK 3 PRIMARY PERMIT#: 18-00005222 ADDRESS: 3565 South Lake Drive Cry: Boynton Beach 3 FURTHER WORK DESCRIPTION: INSTALL ROOM ADDITION TILE ROOF ONLY. Type of Work:❑New ❑J Addition ❑Alteration ❑Repair []Demo ❑Temporary ❑Other VALUE: incl in master pen PERMIT FEE: NET S.F(for SFD's): (SEE FIE SCHEDULE) (ASRVR63I IAS APPLIES) h ❑ OWNER BUILDER PER FL ST.489(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2) ❑✓ CONTRACTOR(CERT.HOLDER): JAMES M FLUKE Ucense#: CGCA 02737. DBA(COMPANY NAME): LANCE CONSTRUCTION, INC Contact Person: JIM FLUKE ADDRESS: 3248 BERMUDA RD STE: CITY: PBG STATE: Florida ZIp:33410 PHONE: 561-236-4470 FAX: XXXX EMAIL: lanceconst©hotmail.com 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 CONDMONERS,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. _ rnorl ! e (Watling (Sre ofOwner or Ann)( udb g cocontractor) ntma Print Name: Joseph A.Spetla,Jr. • Print Name: JAMES M FLUKE 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 PALM BEACH COUNTY OF PALM BEACH Sworn to(or affirmed)and subscribed before me this Swor to(or affirmed)and subscribed before me this day day of 20 19 ,by of • 20 19 ,by (Name of person making statement). (Signature of Notary Public-State of Florida) (Signature of N• c- tate of Florida) (Print,Type,or Stamp Commissioned Name of Notary Public) (Print,Type,or S ,Issloned Name of Notary Public) Personally Known X OR Produced Identification Personally Known V OR Produced Identification Type of Identification Produced Type of Identification Produced JENNIFER 11UTTERWORTH Page 1 of 2 , MY COMMISSION a FF978987 EXPIRES April 26.2020 • 'un 301O10.5 nfl&earysmwn corn