PERMIT DOCUMENTSFOR OFFICE U SIZE ONLY
UNIVERSAL COUNDL--W M.UNICIPAL
FBC Version, Permit Type:
BUILDING PERMIT APPUCATION FORMI Acceptec! ST
_—A-pplication Date:
LL 2013 EdWon AppR 'cation t
Approved for use throughout Palm Beach County and Municipalities
ECK ONE)1: EROPERT Y OWNER: /v
PiUMARY Pi: IT k TENANT:
"IUB-P;: RMFT - 1z Fee &'V.1ue of. a Sub- P&-mft a T-3 covere-I ur4er a ADDRESS, Y(- I /S Ap UNIT:
?r nary Permit corWate boxes I S hi. Ifinot
4, S. 6 & 8 or to ap-p],
'3 d,� 4STATE- 14--f VP:
covered unde-r a Primarper
y rnft' CITY.-/ _Y/V t
cor;iphste the areire ap Kcation to
apply. PHONE., YL 7( FAX:
EMAIL-
I TRAD;E (CHECK ONE):
PRO3EC-1 NAME: T7
STRUCTURAL ROOFING LECT-KiCALI
I PCN:
21 z MIECHANICAL PLUMBING IRE GAS
OTHER:
PRIMARY PERMfT #:
CITY: 77 - /T
-4-
LU.�RTIHER _WORK DESCRIP';ION: sE
Type of V" New Addmor- = Alterat-on Repair = Demo Z T eirporary Other
VALUE:
- PERMIT FEE: NET S.F (for SFE),$)-
CID NER BUILDER PER FL ST. 489(AS NAKIIEDABOVE, FORCONTACT !NFORMLATION SEE BOX 2)
CONTRAC-IOR ,CERT. HOLDER). rp'll j CA License #: 000 0 N1
DSAJCOMP;;� NAME)-
y
ADDRESS: A:'F-f 0-1y: STATE-- zip.-
g—
PHONE EMAIL: / o
Appi
Itcation is hereby made to obtain a pe-mit to do the work and installatio-ns as €€F€ e. 1 certify thatno work or instalIation
has comnm enced prior to the issuance of a perrmit and that al.' work will be peefformed to me_, thestandardsef all laws r4-.g
Wating i
corcuon in thisjuriselce-on. I Understand that a separate pernt�t. must be secureed for El ECTRICAL %NIORK, PLUMBING, SIGNS
-EtiW AN
S, POOLS, FURNACES� BOILERS, HEATERS, TASKS, and AIR CONDITIONERS, etc.
aWNEWSAmm- VIT: I c--rff N that aN the foregoing L-forrnation is acvurate and thel. afl. -work w!7done incompliance With all
Nvacae--- lay's owulating cortstructon, an�a zonitrt-
'A4
Print Name- Al printNarne:
'N NOTARY REQUIRED IF $ 2;SW OR MORE� OR FORALL OXVINER I
fOT ARY R 2,SW OR MORE, 04 FOR ALL OWNER I
BUILDERS REGARD S VALU ATE OF�Ff' RIDA BUILDER:--- REGA�PLFSS OF $ VALUE STATE OrFLORIDA
COUN, -1O�
COUNTYCIF 7, 1 7, T(�' C 7 1-- - eyl -fc '4-
Sworn to for afffirmed) and subscrib-a-d b�fore rrie this Sworn to Cor affirrned) asd subscribed before me this zf Clay
d- By 04 20 a-C by of 20 �O by
z r
*-f No'--y _ .Ec - to of Fia'ecia:l 1Sign-a-W-r a of .14 cl--: 1, Pub I C - stare of F 0 6 -da)
zs ry 7---! (P�r-Lrt -type, P--S--tarnp come d'SdG'-.'fed Nam e of -Nos� ;�Ubklic`1
y .
I Ewe et ROMAN RIon r Type of Identification Produced
:DER
85i5l Page of 2
IRIS FK-W--'E HERDER
EX0',�,S: March 20 2021 .
50'6&� T`'-" �4&:" pubk
202021
'U
Thru N 11Afic
Mike Lang Electric Contract
Scope of Work. -
Home
Owner
Contractor -
1
311,