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:
Approved for use throughout Palm Beach County and Municipalities Application#:
KIND of PERMIT(CHECK ONE): l PROPERTY OWNER: y l2,)S MAT;PS
❑ 9RIMARY PERMIT TENANT: IJl p
/SUB-PERMIT-If Fee&Value of a Sub-Permit are ADDRESS: 1/5/ 4) C Cand Adie UNIT: 14
covered under a Primary Permit,complete boxes L 3 L .5 j& CITY: 6JLor- r'211Ck STATE: ' ZIP: ;9435
8 only to apply.If not covered under a Primary Permit,
complete the entire application to apply. PHONE: 507" FAX: NIA
EMAIL: 9a1D M I ✓ , GmAfi, -Conn
TRADE (CHECK ONE): / PROJECT NAME: W OCTA' Pox
ID STRUCTURAL ❑ ROOFING LECTRICAL PCN: -11-26-Li: D70-0(? 13 0
❑ MECHANICAL ❑PLUMBING o FIRE ❑GAS
o OTHER: LEGAL DESCRIPTION:D7
WW1 IAA Abe3Crsa(33I;•1r:8'4cfb-3 BW7�
PRIMARY PERMIT#: cZ0-4133 ADDRESS: 951 („). O&t.) MIL
CITY: 10+.11 tJ E3sack
FURTHER WORK DESCRIPTION: R Y+oVC O V t I et;/ 5141; , /jht 4-&4$BCI ,i- is W O Ci't15
Type of Work: o New ❑Addition ❑Alteration ❑Repair emo o Temporary o Other /4 w (�
VALUE: '/9 7 t3 PERMIT FEE: (IJ NET S.F(for SFD's): 6a_ Levtio"tine
(SEE FEE SCHEDULE) (AS APPLIES (AS APPLIES)
OWNER BUILDER PER FL ST.489(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2)
f/CONTRACTOR(CERT.HOLDER): Ng- JL94ti1t1 LL-C. License#: U - a 13 ! 7
eC
DBA(COMPANY NAME): Nod o it ec4'ie )G Co qPerson: its
0g
ADDRESS: 54i0. at/li bel A't,VC.- STE: 4CITY: .0/ Sits
Ft- ZIP:3,-aq
PHONE: S6/' t/36. 10/6 FAX: N. 4• EMAIL: 0 O 16/ _#t'f,nA'i/. CeVii
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.
z ■_
4. � a
(Signature of Owner or Agent)(Including contractor) store of Owner or Agent)(Including contractor)
I'rfr
Print Name: Print Name: UR162- aQt19vf bee Pic ide//
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 COUNTY OF
Sworn to(or affirmed)and subscribed before me this Sworn to(or affirmed)and subscribed before me this
day of _ , 20 ,by day of 20 ,by
fName of person making statement) (Name of person making statement)
(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
Page 1 of 2
Printer Friendly Structural Details Page 2 of 2
Land Details
Land Line# Description Zoning Units Acres
1. SFR 1 0.3356
https://www.pbcgov.org/papa/Asps/PropertyDetai I/PrinterFriend lyStrDetail.aspx?entity_id... 10/5/2020
VJ ° eceipt
Parcel ID:
08-43-45-28-15-070-
0280
Address:
451 W OCEAN AVE
BB ,
Application Date:
09/15/20
Owner:
MATIAS IRIS
Application Number./
20 - 4433
Application Type:
DEMOLITION,
INTERIOR
Thank you for your payment.
Transaction Results
Transaction Status:
Success
Authorization Code:
01630C
Reference Number:
https:/1byb2-egov.aspgov.com/Click2GovBP/hub-payment-flow.html 9/16/20, 12:25 PM
Page 1 of 3
I .
115775077
Payment Method
Charged To:
Visa ""4059 _
Account Holder:
morzeila, andy j
Billing Address:
1306 summerwood circle, wellington, FL 33414
Transaction Overview
Total Amount:
li
$122.25
Payment Date:
09/16/2020 12:20 PM
. I
Charge Details
Charge Description Amount
PAPER SUBMITTAL COORD FEE (CF) $25.00
DBPR BLDG CODE ADM & INSP (DB) .$2.00
DEPT COMMUN AFFAIRS SURCH (DC) $2.00
GREEN BUILDING FEE (GR) ' $0.25',
PERMIT FEES (PF) $75100
TECHNOLOGY FEE (TF) $2.00
SCAN UP TO 11X17 PP1SIDE (1S) $16.00
Total $122.25
I ,
haps://byb2-egov.aspgov.com/Click2Gov8P/hub-payment-flow.html 9/16/20, 12:25 PM
Page 2 of 3