PERMIT DOCUMENTS UNIVERSAL COUNTY-WIDE/MUNICIPAL FOR OFFICE USE ONLY
BUILDING PERMIT APPLICATION FORM FBC Version: 2Lf�• Permit Type: O'fLa2
Accepted By: ApplJJ'CCa eQ�Ji�D te:
July 2013 Edition Application II: )- c7�"I
Approved for use throughout Palm Beach County and Municipalities
I2 VOM SAAL RICHARD S & PAMELA
KIND of PERMIT(CHECK ONE): PROPERTY OWNER:
❑✓ PRIMARY PERMIT TENANT:
❑SUB-PERMIT-If Fee&Value of a Sub-Permit are covered under a ADDRESS: 701 NW 8TH CT UNIT:_
Primary Permit,complete boxes Li.4 5 6 &8 only to apply.If not CITY: BOYNTON BEACHSTATE: FL Zip-33426
covered under a Primary Permit,complete the entire application to
apply. PHONE: 561-734-2916 FAX:
EMAIL:
I fi
TRADE (CHECK ONE): PROJECT NAME: VOM SAAL RICHARD S&PAMELA
['STRUCTURAL ['ROOFING ❑ELECTRICAL08-43-4520-12-000-0120
❑MECHANICAL ❑PLUMBING ❑FIRE ❑GAS PCN:
❑ OTHER: LEGAL DESCRIPTION:GLEN ARBOR LTS 12 & 13 (LESS
PRIMARY PERMIT#: ADDRESS: 701 NW 8TH CT
CITY: BOYNTON BEACH
I
FURTHER WORK DESCRIPTION: HURRICANE IMPACT WINDOWS INSTALLATION
Type of Work:✓❑Flew ❑Addition ❑Alteration ORepair ODemo Temporary 00ther
VALUE: $ II f 90 0 •u o PERMIT FEE: NET S.F(for SFD's):
(SEE FEE SCHEDULE) IAS APPLIES) IAS APPLIES)
fi
❑ OWNER BUILDER PER FL.ST.489(AS NAMED ABOVE, FOR CONTACT INFORMATION SEE BOX 2)
I] CONTRACTOR(CERT.HOLDER): Dependable Shutter Service License If: 4 -oil6?-1
DBA(COMPANY NAME): ways, 7t?ro v Contact Person: Surita Sirju
ADDRESS: 4741 Orange Drive STE: CITY: Davie STATE: FL ZIP: 33314
PHONE: 954-583-1411 FAX: 9547914)840 EMAIL: iaviles@dependableshutterservice.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 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
applicabl:daws reguld ing construction and ening.
_
2 -'0�1✓' 'i ��. T
(c at
nure of Owner or Asend lindudina contractor) (Signature of Contractor)
Print Name: 2:./,...,,A V o va-, Set I print Name: 1414 7----c- —pro ..--/
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 /-12/M in,,. Cit COUNTY OF Pia... e- S
Sworn to(or affirmed)and subscribed before me this L d Sworn to(or affirmed)and subscr'^••,:.• me a this / v day
RYA`
day of vU0/w..��•r 20 �iJ ,by of Itio"o'..-d loo 2fi C i
/2tom,. 1 406 cDnms1°Pher
•G a - seed CrCrc .--r ! trrt„sa� Co,...'^mIssi,, EdWard
(Name el anon rt ). (Name Marson / 1. -vcrev.• :coder/ Pir 035739
ffiFlorio::rough eCy.2 Z ?
_// � tag,p ola,v
DbliC
(Signature of Notary Public-State of Florida) (Signature of Nota 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 tr6R Produced Identification
Type of Identification Produced . Type of Identification Produced
Page 1 of 2
L
Y PDB Christopher Edwards
�� Commission GG 3572-2�..„ Commission Expires 07-22-8��° Bonded Through-Cynanotarya.•o-FFvO Florida-Notary Public