APPLICATION
.. NraW h I ~..~~=~~~-
B U I L 0' I N G .VoLE rl R ~ M E
.. '. ,--,..--,'.., ' "BUILDING PERMIT APPLICATION
..,..:'. ..".q'M;....:_ 0, I, (Please Print)
PCN 05J.U:J. 4llJ-oI-O,;1._ 00(,0,
.. "'(Palm 'Beach" CountY',~rope;ty'~ontror/l) ,,':I~'~{~ 'I: .
., --Owner' s Name=,-,,~..rEr2.S,(Zo'N ~1.1= t\ ~')I::::,'T rl 16 Owner's Phone fl 134-5000
~;r's ~~~~W~~.~S1=: ~,F _
State t==l.- ,Zip 334-%
Fee Simple-Titleholder's Name' ',., , 'l;,
". . .._,._ ' " ' (If other than owner)
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Permit fI ~ -4 - 18- 9' S
(lOR SUB PERMITS ONLY)
Fee Simple Titleholder's Address
Contractor's Phone fI(~~),96~-A(~9/
~
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Bonding Company
Bonding Co.Address City State
Architect/Engineer's Name
Architect/Engineer's Address'
Mortgage Lender's Name
Mortgage'Lender's Address
SINGLE FAMILY:___ DUPLEX:___ MULTI-FAMILY:___ HOTEL:___ RETAIL:___ OFFICE:~ INDUSTRIAL:___
(check one) ,
ESTIMATED VALUE OF CONSTRUCTION: $ "'3 c:;::J z:;)
DESCRIPTION OF WORK: /,....,S.ToU.... c;:::.., ~ '::;'Il r:;1if,.J~~r--
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 tOHmeet' the standards of all laws regulating construction in this
jurisdiction. I understand ,that a seQarate permit must be secured for ELECTRICAL WORK,
PLUMBING; SIGNS~ WELLS,POOLS'. FURNACES, BOILERS, HEATERS, TANKS, and AIR CONDITIONERS, ETC.
. ;!l: '
OWNER!S_AFFIDAVIT: I. .certifYJlthat 'all the foregoing information is accurate and that all work
,,!~~!...!e 40ne in compliance :wlth'.,;a~l:,;applicable laws regulating construction and zoning. ,
~ .~ ":",~._~&_..,-,,...,...~._~...... t,' .iJ .~.. ".1, - ~ -. ...-.... _"'__.. " " .
WARNIRG,-TO OWRIIl:.., YOUR,.rAILlJD''l'O DCORD A NOTICE or CDIIIRCIMINT MAY 1lISULT IIi YOUR PAYING
'l'WICE JOll IKPROVIKIR'l'S 'l'O YOUR ~PROPBRrY . IJ' YOU IRTIND 'l'O OBTAIH rIHAMCIMG. COHStn.T WITH YOUR
LENDER OR AM ArI'OII1KY BDOD(DCOJmIRG YOUR NOTICE 01' CCIItIHCIlMIRT.
,.'. . ,- ..". .. . _,. _ ..',l-' ..
Property'Ovner's or AaeDt's Sipature Date
STATE"OF--FLORIDA, COUNTY OF PALMfBEACH
The foregoing instrument was acknowledged before me this (date) by
, who is Qersonally known to me or wno nas proouc~o
(eype of identification) as identification and who did ~did not) take an
oaen. ~'
(SEAL)_.....-.. .. .-, h' , , ;
Signature of person taking. acknowledgement ., ,
Nameof'officer taking;act,nowledgement--typeo, pr1nteO or seampeo
Title"or-rank'1 . . '" ",1, .1 Serial number, if any
Contractor.s Signature
STATE OF FLORIDA. CO
'- .....r,. - .-
The foregoing instrum
I "
Date
an
V\€e~ +0 ~
, ,CU..L, .
Permit Officer
Date:
. ......
Any change in building"plans ot' specifications must be recorded with this office. Any work not
covered above must have a, valid permit prior to starting. In consideration of the granting of
this ~et'mit, the owner and builder agree to erect this structure in full compliance with the
Build1ng and Zoning Codes of the City of Boynton Beach.
'-NOTE':~T;This permit VOII(after :180 DAYS UNLESS the work which it covers has been commenced. All
Contra~tors must have ,valid State Certification or County Competency plus County and City
Occupatio~al Licenses1pri'or to obtaining permit. . ,
't i ~ i .
I .' '1..' t.v,!:1
ISSUANCE OF THIS PERMIT DOES NOT AUTHORIZE VIOLATION OF DEED RESTRICTIONS
THIS PERMIT OR PLANS FILING FEE IS NOT REFUNDABLE