PERMIT APPLICATIONBP200101
CITY OF BOYNTON BEACH
Application Inquiry
Application number ..... : 01 00002992
Application status, date : CERTIFICATE OF COMPLETION
Property .......... : 3609 S FEDERAL HWY
PCN ............. : 08-43-46-04-00-000-1060
Lot Number ......... :
Zoning ........... : C3 COMMUNITY COMMERCIAL
Application type ...... : BM BLDG-MISC-COMPLETION
Application date ...... : 7/23/01
Tenant nbr, name ...... : CHEZ GOURMET
Master plan nbr, revwd by : JP
Estimated valuation .... : 5000
Total square footage .... : 0
Public building ...... : NO
Work description, qty . . . :
Pin number ......... : 6259
Press Enter to continue.
F3=Exit F5=Land inq
F10=Fees F11=Receipts
F7=Appl names
F12=Cancel
F8=Tracking inq
F13=Val calcs
1/30/02
13:34:28
1/29/02
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DEPARTMENT OF DEVELOPMENT
BUILDING DIVISION
BUILDING PERMIT APPLICATION
PCN#
Fee Simple Title'Hold6r's Name
Fee Simple Title Holde¢s Address
Ci~/State~ip
Company Addre~ 7~ q
Ci~/State~ip ~ ~
Bonding ~mpany ~lj/
Bonding Company Addre~ ~
Ci~/State/Zip
(Palm Beach County Property Control #)
(If other than owner's)
(If other than owner's)
Zoned
Architect/Engineer's Nam&
Architect/Engineer's Address
City/State/Zip
Mort a
g ge Lender's Name
Mortgage Lender's Address
City/State/Zip /V ,/~
(Check one below) t ,
Single Family Duplex Multi-Family Hotel Retail ~ Office Industrial
Electrical Mechanical ~---Plumbing Structural ~ Fire Other
Application is hereby required to obtain a permit to do 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 codes, laws, rules and regulations goveming
construction in this jurisdiction. I understand that a separate permit must be secured for, ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS,
FURNACES, BOILERS, HEATERSi TANKS and AIR CONDITIONING WORK, ETC.
OWNER'S AFFIDAVIT: I certify that all the fore
applicable codes, laws, rules and regulations
Property Owner's or Agent's Signature
STATE OF FLORIDA, COUNTY OF PALM
The foregoing instrument was
acknowledged before me this
Who is personally known to me or who
has produced
(SEAL)
rate and that all work will be done in compliance with all
(date) by
As identification and who did (did not) take an oath.
Signature of person taking acknowl~lgement . /~
Name of officer taking ackno~.'me~pe~, p,l~qd or stamped
Title or rank / .~'/ // ~ //1~ / ~
Contractor's Signature ~//~.////~ ~' Serial Number, "any
T //'""~- ' ~' ~' Date /~ L/ / /~ ~/__~
S ATE OF FLORIDA, ~TY OF PALM BEA~
The foregoing instmment was , ~ ,,,j__, y~,,~ X /V~,4
acknowledged before me this / ~- [ ~ ~ (date) b _
-- ~ ~}{ U ~ -[ ' entifi~tion and ~o did (did not) ~ke an oa~.
~~r~ki,iu~C~Ment ~pe~rihted or s[a~d - ' ~
Title or rank Serial Number, if any
Contractor's State Certification of Registration No.
Liability Insurance Expiration Date
Application Approved by
(Certificate of Competency Holder)
Workers' Compensation Expiration Date
(Permit Officer) Date
Any change in building plans or specifications must be recorded with Ihls office. Any work not covered above musl have a valid permit prior lo starting. In consideration of grants this permit, the
owner and building agree 1o erect this structure in full comcliance with the Building and Zoning Codes of the City of Boynton Beach.
NOTE: This permit VOID after 180 DAYS UNLESS the work which it covers has commenced. All Contractors must have valid State Certification or County Competency
plus County and City Occupational Licenses prior to obtaining permit.
ISSUANCE OF THIS PERMIT DOES NOT AUTHORIZE VIOLATION OF DEED RESTRICTIONS
FEES ARE NOT REFUNDABLE
S:\DEVELOPMEN%FORMS&TEMPLATES\BUILDING PERMIT APPLICATION-Igl. Rev 6/18/97, 11/4/97, 12/98, 6/99, 8/99, 5/00, 6/00, 9/00, 10/01
FF-- HF--
Application Accepted By:
Application #
Type of Construction
Occupancy Type
Fence Type
Roof Type
Flood Zone
Base Flood Elevation
Finish Floor Elev. (Proposed)
Number of Units
Parking Spaces Required
Parking Spaces Provided
Area Square Feet (Gross)
Area Square Feet (Net)
Number of Stories
Number of Bedrooms
Remarks:
IF THIS BOX IS NOT COMPLETED, THIS PERMIT IS
SUBJECT TO A FINAL INSPECTION ONLY.
AUTHORIZED for CERTIFICATE OF OCCUPANCY:
Date
AUTHORIZED for CERTIFICATE OF COMPLETION:
Date
ADDITIONAL FEE(S)
BCAIF
Parks Fee
Penalty Fee
Public Building Fee
Radon Fee
Road Impact Fee
School Fee
Sewer Fee
Water Fee
Fire Department Fee
Overtime Fee
Sub-Total
SINGLE FEE
__ Building
__ Clearing & Grubbing
__ Drainage
Electrical
Excavation
Fill
__ Fire Sprinkler
__ Irrigation
__ Landscaping
Mechanical
Paving
Plumbing
Roofing
Sign
Site Lighting
Sub-Total
TOTAL
Less Plan Filing Fee
Receipt Number
Check/Credit Card Number
Cash
Received from:
VALUE
FEE
Accepted by: (Initials
DEPARTMENT OF DEVELOPMENT
BUILDING DIVISION
BUILDING PERMIT APPLICATION
(Please Print)
Permit #~l- ~-_P-'l<~ i~.
(FOR SUB PERMITS ONLY)
PCN# . (Palm Beach County Property Control #)
Owner's Name r~...<:::) ,~"~..3~:~ "~,c_~-z¢>,. owner's Phone ~ ~ ~ [~ ~--
Owner's Address ~ ~t ~. ~~ ~ V
City ~ ~ ~ ~ ~.~ 'State ~ ~ Zip ~~
Fee Simple ~ille Holder's Name (If other than owner's)
Fee Simple Title Holder's Address (If other than owner's)
Contractor's Name ~~ ~ ~~. ~ontractor's Phone ~ ~- ~q~ ~%
Project Manager and emergency phone ~ ~~~ ~ ~.~ .~~
Contractor's Address ~ ~ ~~ ~ ~/~ Beeper/Fax ~ .
City ~.~,~. X - - - State [ 4 L~
Job Name ~~ ~ O¢ ~ ~
Job Address , _ x t --
. Description
Legal
Bonding Company
Bonding Co. Address City Slate
Architect/Engineer's Name ~ ' -
Architect/engineer's Address ~
Modgage Lender's Name
Morlgage Lender's Address
SINGLE FAMILY DUi'LEX MULTI-FAMILY HOTEl._ ...... RIH'AIL ,,-"/OFFICE__ INDUSTRIAL
(check one)
ESTIMATED VALUE OF CONSTRUCTION $
DESCRIPTION OFWORK: :~OP~:) ~'--,r' ~1 _~u z~-'r35.. { { ~/~. ~,, t'l~ , ' .
Application is hereby required to obtain a permit to do 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 codes, laws, rules and
regulations governing construction in this jurisdiction. I undersland that a separate pemfit must he sec ~red for ELECTRICAL, PLUMBING,
SI~HS, WELLS, POOLS, FURNACES, BOILERS, HEARERS, TANKS AND AIR CONDITIOHIN~ WORK, ETC.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all wolk will be done in compliance with all applicable
codes, laws, rules and regulations governing construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECO~D A NOTICE ~)~/COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR ~;~R~P, EiRT)f'. IF/YpU INTEND ~ OBTAIN FINANCING, CONSULT
WITH YOUR LE~DER OR ~N ATTORNEY ~~~~~~O;l~ COMMENCEMENT.
Prope~yOwnersorAgentsSignature ~ l ~ ~ ~ A /I I ~ Date
STATE OF FI,OR1DA, COUNTY OF PALM BEACI~
i~,,p~0nally ~own to ~ne or who has produced
;~; ,,,, oa~. "' , //~ . as identilicatio,, ~,tl who did (did not)
Signature of per,on ~aking ~nowledgem~~F~ amc o[ officer ~aking acknowledgement - l~ed.
pdnt~ or mmp~ " ~~ j~ Serial ~umbcr, irany
Contractor s Signa,~~~ Date
'~ O~'I'Y OF PALM BEA
STA~ OF FI,O~DA, CO~'I'Y OF PALM
The foregoing instrument was acknowledged bcforc n
who is e.p..~o.ally known to.?c or who has produced
take a~! Oalll.
Signaturo of person laking acknowledgerae,.~rill~ .~r~m/t~ k' ~' ....
primed or stamped
Co.tractor's State Certification of Registration No.
Liability Insurance Expiration Date
Workers' Compensation Expiration Date
Application Approved By
..... ~s identification Mud who did (did not)
,..~"~ Lynn ]eon Wickham
~ MY COMMISSION # CC9825~5 EXPIRES
~; Decem~r [ 2004
~,~' so.~0
Name or officer laking ack.owlcdgcnmnt - lypcd,
Serial Numbcr,
(Cedific~te of Competency Holder) * ' ~ Lynn ~an ~k~m
~" ~ ~cem~r ~ 2~4
Permit Officer Date:
Any change in building plans or specifications must be recorded with this office. Any work no! covered above must have a valid permit prior
to starling. In consideration o1' granting this permit, the owner and builder agree to erect this structure in full compliance with the Building
and Zoning Codes of the City of Boynton Beach.
NOTE: This permit VOID after 180 DAYS UNLESS the work which it covers has commenced. All Contraclors must have
valid Slate Certification or County Competency plus Courtly and City Occupalional Licenses prior lo obtaining permit.
ISSUANCE OF THIS PERMIT DOES NOT AUTHORIZE VIOLATION OF DEED RE~TRICTI0tV /.,d," '"
FEES ARE NOT REFUNDABLE ~,.,,~0
'0r')l\~.! 'M]'d'~IH'V).~ ' ' ,'- .~r ~ ' "rPF' '"' ' V':l,'~, H F ,~ r', .... ,'.,~.. ,~,~,
ApplicatIon #
Master Plan #
APPLICATION DATE:
RECEIVED BY:
SETBACKS: LEFT
RIGHT
FRONT
REAR
ZONE:
TYPE OF CONSTRUCTION
OCCUPANCY TYPE
ROOF TYPE
FENCE TYPE
AREA SQUARE FEET
FLOOD ZONE
BASE FLOOD ELEVATION
FINISH FLOOR ELEVATION
NUMBER OF STORIES
NUMBER OF UNITS
PARKING SPACES REQUIRED
PARKING SPACES PROVIDED
# OF BEDROOMS
# OF BATHROOMS
ROAD IMPACT FEE
SEWER FEE
WATER FEE
PARKS FEE
SCHOOL FEE
PUBLIC BLDG. FEE
LAW ENFORCEMENT FEE
RADON F'E'E
BCAIF
ADDITIONAL FEE
PENALTY FEE
SUB-TOTAL
REMARKS:
SINGLE FEE
site Improve.
Building
Electrical
Mechanical
Plumbing
Roofing
Drainage
Excavation
Landscaping
Paving
Sign
Sewer
SUBTOTAL
VALUATION
F,EE,
REQUIREMENTS for
CERTIFICATE OF OCCUPANCY
CERTIFICATE OF COMPLETION
FINALS:
SITE SIGN
FIRE FENCF_JBUFFER WALL
DRAINAGE
PAVING OTHER
SITE LIGHTING OTHER
AUTHORIZATION for CERTIFICATE OF OCCUPANCY:
Date
AUTHORIZATION for CERTIFICATE OF COMPLETION:
Date
TOTAL
LESS PLAN FILING FEE
TOTALAMOUNT, DUE
RECEIPT NUMBER
DATEISSUED
INTERIM SERVICES FEE CALCULATIONS:
Residential:
X
# of Units Applicable
Monthly Fee
Commercial:
# of Sq. Fl
Base Sq. Ft
Divided by 1,000
(rounded to
Nearest tenth)
X
Applicable
Monthly Fee
Intedm
Services Fee
Base Sq. Ft
Rate
interim
Services Fee
,l~V F.! (WM I:H*I~:F~!~ M,~ I~(~('\I'F!~ MIT A;'I'I .I('/\'I'I(~H.I)()C
DEPARTMENT OF DEVELOPMENT
BUILDING DIVISION
BUILDING PERMIT APPLICATION
Date:
PCN#
Fee Simple Title s Name
Master Permit #
Fee Simple Title Holder's Address
City/State/Zip
Company Address '~ .~'"'1
City/State/Zip
Bonding Company
Bonding Company Address
City/State/Zip
Architect/Engineer's Name
ArchitectJEngineer's Address
City/State/Zip
Mortgage Lender's Name
Mortgage Lender's Address
City/State/Zip
(Check one below)
oi- Z.q
,0
Permit #
(Palm Beach County Property Control #)
(If other than owner's)
(If other than owner's)
Pager/Fax-# ~'J'~ ~/'d' ~/' 0~/o ~
Zoned
Single Family Duplex Multi-Family Hotel
(Check Reviewer Required below)
Retail ~ Office Industrial
Electrical ~chan ca Plumbing __ Structural ~,,~_ Fire Other
Application is hereby required to obtain a permit to do work and installations as indicated. I certify that no work or installation has commenced pdor
to the issuance of a permit and that all work will be performed to meet the standards of all codes, laws, rules and regulations governing
construction in this jurisdiction. I understand that a separate permit must be secured for, ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONING WORK, 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 codes, laws, rules and regulations governing construction and zoning.
Property Owner's or Agent's Signature Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was
acknowledged before me this (date) by
Who is personally known to me or who
has produced As identification and who did (did not) take an oath.
(SEAL)
Signature of person taking acknowledgement
Name of officer taking acknowledgement typed, printed or stamped
Title or rank ~ Sedal Number, if any
Contractor's Signature ~_...~ ~ / ::~/
Date
I'/
STATE OF FLORIDA, COUNTY OF PAL~'~"~~~
The foregoing instrument was
hasWh°producediS personally known to me or who~T2 L. ,~ ~.~"',..~ . ,.~f. yt! _ ~ 7 -c~...%?., ~ ~ As identification and who did (did not) take an oath.
Signature of person taking acknowledgement
Name of officer taking acknowledgement typed, printed or stamped '
Title or rank umber, if any
..,.~% Patricia A Berger
(Certificate of Competency Holder) *~I~'* My Commission CC889455
Contractor's State Certification of Registration No. ~ ~ (~'~ ~:: ( I ~ ~0 '~',~X~,'" Expires January 07 2004
Liability Insurance Expiration Date Workers' Compen n Date
Application Approved by (Permit Officer) Date
Any change In building plans or specilicelions must be recorded with this office. Any work riel covered above must have a valid permit prior to slatting. In consideration of grants this pe~nil, Iha
owner and building agree to erect this stnJcture in full compliance with the Building and Zoning Codes of the Cily of Buynlon Beach.
NOTE: This permit VOID after 180 DAYS UNLESS the work which it covers has commenced. All Contractors must have valid State Certification or County Competency
plus County and City Occupational Licenses prior to obtaining permit.
ISSUANCE OF THIS PERMIT DOES NOT AUTHORIZE VIOLATION OF DEED RESTRICTIONS
FEES ARE NOT REFUNDABLE
S:~DEVELOPMEN'IAFORMS&TEMPLATES~BUiLDiNG PERMIT APPLICATION-Icl. Rev 6/18/97, 11/4/97, 12/98, 6/99, 8/99, 5/00, 8/00, 9/00, 10/01
Application Accepted By:
Application #
Type of Construction
Occupancy Type
Fence Type
Roof Type
Flood Zone
Base Flood Elevation
Finish Floor Bev. (Proposed)
Number of Units
Parking Spaces Required
Parking Spaces Provided
Area Square Feet (Gross)
Area Square Feet (Net)
Number of Stories
Number of Bedrooms
Remarks:
IF THIS BOX IS NOT COMPLETED, THIS PERMIT IS
SUBJECT TO A FINAL INSPECTION ONLY.
AUTHORIZED for CERTIFICATE OF OCCUPANCY:
Date
AUTHORIZED for CERTIFICATE OF COMPLETION:
Date
ADDITIONAL FEE(S)
BCAIF
Parks Fee
Penalty Fee
Public Building Fee
Radon Fee
Road Impact Fee
School Fee
Sewer Fee
Water Fee
Fire Department Fee
Overtime Fee
Sub-Total
SINGLE FEE
Building
__ Clearing & Grubbing
__ Drainage
Electrical
Excavation
Fill
Fire Sprinkler
__ Irrigation
__ Landscaping
Mechanical
__ Paving
__ Plumbing
Roofing
Sign
Site Lighting
Sub-Total
TOTAL
Less Plan Filing Fee
Receipt Number
Check/Credit Card Number
Cash
Received from:
Accepted by: (Initials)
BALANCE DUE
VALUE
FEE
Receipt Number
Check/Credit Card Number
Cash
Received from:
Accepted by: (Initials)
S:\DEVELOPMENT',FORMS&TEMPLATES\BUILDING PERMIT APPLICATION-Igl, Rev 6/18/97, 11/4/97, 12/98, 6/99, 8/99, 5/00, 8/00, 9/00, 10/01
DEPARTMENT OF DEVELOPMENT
BUILDING DIVISION
BUILDING PERMIT APPLICATION Rec. #
(Please Print)
COMPLETE EACH BOXED ENTRY Permit #
(FOR SUB PERMITS ONLY)
PCN# ~ ~' ~"'~- ~"'~' "' 0~-- 0 0 ' O0 '/0~0 (Palm Beach County Property Control g)
JOwner's Nam~ ~~~~ ~~ ~ _~r~. IOwner's Phone ~ ~~~~-
Owner's Address ' ~ ~ .. ~ ~~
ee Simple Title Holder s Name (If other t~an owner's)
Fee Simple Title Holder's~rr~/s , (If ~ber than owner's)
~Compan~ ~'~ ~'~ ~J~G ICompanyPhone,~ ~[~[~-~
C6m Address
State j.~..[ Pager/FaX#~zip ~
. .
Job Addres~ fi"'" r~
Legal Descrip~h~'~'-'~:~':~ ~ ~ ....
~:' ~ .......... ~ ' Zoned
Bonding Comp' n~ ~:i ,uUL ~O ~ ~_
Bonding Co. A Jdre~s j ~ City State
ArchitecFEngi¢ ~r;~i~;~~ ~,~; ~~~ ~ ~--~ ~~
Mortgage Lender's Name
Mortgage Lender's Address
SINGLE FAMILY __ DUPLEX __ MULTI-FAMILY __ HOTEL RETAIL ~ OFFICE INDUSTRIAL
check one) --
ESTIMATED VALUE OF CONSTRUCTIONJ $ ..~'-~;;~o ,. oo
DETAILED DESCRIPTION OF WORK:I ~
CHECK REVIEWER REQUIRED:
~ ~ ~ ~STRUC'I1 FIRE ~OTHERl
Application is hereby required to obtain a'perm t to do-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 codes, laws, rules and
regulations governing construction in this jurisdiction: I understand that a separate permit must be secured for ELECTRICAL, PLUMBING,
SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS AND AIR CONDITIONING WORK, 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
codes, laws, rules and regulations governing construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RE~
.~ORD A NOTI_CE~E.~COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOI~tlpROPER~YO~ INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNE-'Y.I~aRI;;I~ ~,F_.C~D. Hr~ YOOR NOTICF-.OF~OMMENCEMENT.. .
Property Owner's or Agent's Signature ~- Date ~
The foregoing instrument was acknowledged before me this (date) by
wh.._~o is personally known to me or who has produced as identificationJnd'who'c~id"~did not)
-take an °ath' '~ ~ Christina Ouifarr°
(SEAL) '~J~.~' Exoires December 08, 2003
Signature ofp"~l~n~'king acknowledgement _~ Name of officer taking acknowledgement - typed,
printed or stamped ~;~___rI'itlfi o'r'~
rank/'3 . ,, Serial Number, if any
Co '
S T.~ ';]~ c(~ ;~ oS iRgig n;At,~TY[O_~ p A~M_B EA C(~H~ ~-~ t(j~l~-~~J~ Date / ~/2. ~/~.)~
The foregoing instrument was acknowledged before me this
who is personally known to me or who has produced
take an oath.
(date) by
as identification and who did (did not)
(SEAL)
Signature of person taking acknowledgement
printed or stamped
Title or rank
Name
of officer taking acknowledgement - typed,
Serial Number, if any
(Certificate of. Cpm. peteQfiy Holder)
Contractor's State Certificatio~ Registration ~,~.,."D :..j~ ~ ~.;"(~.O 5 "~ [,,'~//-g/ _ .
Liability Insurance Exp[r, att'5~ Da,~/'~, J~..-Y ~";- './" ~? t//-~ . //,,--/~' ~ /
Workers'Compensati~~_ ~.~.. '--- ~..~ (t.-~,~---. '"'" /'
Any change in building I~ns or spec ~icm.:; ~ded with this office. Any work not covered above must have a valid permit prior
to starting. In consideration of granting ,. :,~C~~ner and builder agree to erect this structure in full compliance with the Building
and Zoning Codes of the City of Boynton Beach.
NOTE: This permit VOID after 180 DAYS UNLESS the work which it covers has commenced. All Contractors must have
valid State Certification or County Competency plus County and City Occupational Licenses prior to obtaining permit.
ISSUANCE OF THIS PERMIT DOES NOT AUTHORIZE VIOLATION OF DEED RESTRICTIONS
FEES ARE NOT REFUNDABLE
J:\SHRDATA\DEVELOPMENT~FORMS.DOC\PERMIT APPLICATION A.DOC - Revised 6/18/97, 11/4/97, 12/98. 6/99, 8/99, 5/00, 8/00, 9/25/2000
APPLICATION #
APPLICATION DATE:
SETBACKS:
ZONE:
(THIS SIDE FOR OFFICE USE ONLY)
LEFT
RIGHT
MASTER PERMIT #
APPLICATION ACCEPTED BY:
FRONT REAR
TYPE OF CONSTRUCTION
OCCUPANCY TYPE
FENCE TYPE
ROOF TYPE
FLOOD ZONE
BASE FLOOD ELEVATION
FINISH FLOOR ELEV. (PROPOSED)
NUMBER OF UNITS
PARKING SPACES REQUIRED
PARKING SPACES PROVIDED
AREA SQUARE FEET (GROSS)
AREA SQUARE FEET (A/C)
# OF STORIES
# OF BEDROOMS
ADDITIONAL FEE
BCAIF
PARKS FEE
PENALTY FEE
PUBLIC BLDG. FEE
RADON FEE
ROAD IMIbACT FEE
SCHOOL FEE
SEWER FEE
WATER FEE
FIRE DEPT. FI~E
OVERTIME FI~E
SUB-TOTAL
REMARKS:
Recpt #
Cash
VALUATION
SINGLE FEE
Building
Clearing & Grubbing
Drainage
Electrical
Excavation
Fill
Fire Alarm
Fire Sprinkler
Irrigation
Landscaping
Mechanical
Paving
Paving/Drainage
Plumbing
Roofing
Sign
Site Lighting
SUB TOTAL
TOTAL
LESS PLAN FILING FEE
Rec'd froth:, ,
Accepted by: (Initials)
.FEE
IF THIS BOX IS NOT COMPLETED, THIS PERMIT IS
SUBJECT TO A FINAL INSPECTION ONLY.
AUTHORIZED for CERTIFICATE OF OCCUPANCY:
Date
~BISED for CERTIFICATE OF COMPLETION:
, C/- ! /
Recpt #
Cash
BALANCE DUE
CK#
Rec'd from:
Accepted by: (Initials)
J:\SHRDATA\DEVELOPMENT~FORMS.DOC\PERMiT APPLICATION A.DOC - Rev sed 6/18/97, 11/4/97, 12/98, 6/99, 8/99, 5/00, 8/00, 9/25/2000
DEPARTMENT OF DEVELOPMENT
BUILDING DIVISION.
BUILDING PERMIT APPLICATION
Date: Master Permit # Permit # O { -- ~ c~ c~' ~_~ '
PCN# (Palm Beach County Property Control #)
Fee Simple Title Hold~f~N~me ' (If other than owners)
Fee Simple Title Holders Address (If other than owners)
Ci~lS~te~ip
Company Address
Ci~/S~te~ip
Bonding Company
Zoned
Bonding Company Address
City/State/Zip
Architect/Engineer's Name
Architect/Engineer's Address
City/State/Zip
Mortgage Lender's Name
Mortgage Lender's Address
City/State/Zip
(Check one below)
Single Family
Duplex
'-' ulti-Family
Hotel Retail
Office Industrial
(Check Reviewer Required below)
Electrical ~ Mechanical Plumbing Structural Fire Other
Application is hereby required to obtain a permit to do 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 codes, laws, rules and regulalions governing
construction in this jurisdiction. I understand that a separate permit must be secured for, ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONING WORK, ETC.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance witli all
applicable codes, laws, rules and regulations governing construction and zoning.
Property Owner's or Agent's Signature
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was
acknowledged before me this
Who is personally known to me or who
has produced
(SEAL)
Signature of person taking acknowledgement
Name of officer taking acknowledgement typed, printed or stamped
Title or rank
(date) by
Date
Cent ra ctor's Signature /J~.w~-~/
The foregoing instrument was
As identification and who did (did not) take an oath.
Date
v , Sedal Number, if any
?
As identification
a~l~j~l~l~ll~lM C~ke an oath.
acknowledged before me this
Who is personally known to ~,aol~o
has produced ~,v%.'~ Dorms
(S~L) ~~~~,~
Signa~re of pe'~ taking a~no~edgement
Name of offi~r taking ackno~edgement ~ped, p~nted or s~mped
Title or rank .- - Serial Number, if any
(Certificate of Competency Holder)
Contractor's State Certification of Regi~on No. ~'~C'-- 000//~//q
Liability Insurance Expiration Date ! Ir'd \ j~ .~vyq~kers' Compensation Expiration Date
Application Approved by ~~ [~.4~.~ {PermitO~cer) Date
Any change in building plans or specifications must be recorded with this office. Any work not covered above must have a valid permit pdor to starting. In consideralJon of grants this pein'it, the
owner and balding agree to erect this structure in full compliance with the Building and Zoning Codes of the City of Boynton Beach.
NOTE: This permit VOID after 180 DAYS UNLESS the work which it covers has commenced. All Contractors must have valid Slate Certification or County Competency
plus County and City Occupational Licenses prior to obtaining permit.
ISSUANCE OF THIS PERMIT DOES NOT AUTHORIZE VIOLATION OF DEED RESTRICTIONR
FEES ARE NOT REFUNDABLE
S:\DEVELOPMENT~FORMS&TEMPLATES\BUILDING PERMIT APPLICATION-Igl. Rev 6/18/97, 11/4/97, 12/98, 6/99, 8/99, 5/00, 8/00, 9/00, 10/01
Application Accepted By: Application #
Type of Construction
Occupancy Type
Fence Type
Roof Type
Flood Zone
Base Flood Elevation
Finish Floor Elev. (Propcsed)
Number of Units
Parking Spaces Required
Parking Spaces Provided
Area Square Feet (Gross)
Area Square Feet (Net)
Number of Stories
Number of Bedrooms
Remarks:
IF THIS BOX IS NOT COMPLETED, THIS PERMIT IS
SUBJECT TO A FINAL INSPECTION ONLY.
AUTHORIZED for CERTIFICATE OF OCCUPANCY:
Date
AUTHORIZED for CERTIFICATE OF COMPLETION:
Date
ADDITIONAL FEE(S)
BCAIF
Parks Fee
Penalty Fee
Public Building Fee
Radon Fee
Road Impuct Fee
School Fee
Sewer Fee
Water Fee
Fire Department Fee
Ovedime Fee
Sub-Total
SINGLE FEE
Building
__ Clearing & Grubbing
__ Drainage
Electrical
Excavation
Fill
Fire Sprinkler
Irrigation
Landscaping
Mechanical
Paving
Plumbing
__ Roofing
__ Sign
__ Site Lighting
Sub-Total
TOTAL
Less Plan Filing Fee
Receipt Number
Check/Credit Card Number
Cash
Received from:
Accepted by: (Initials)
BALANCE DUE
VALUE
.FEE
Receipt Number
Check/Credit Card Number
Cash
Received from:
Accepted by: (Initials)
S:\DEVELOPMENT~FORMS&TEMPLATES\BUiLDING PERMIT APPLICATION-Igl. Rev 6/18/97, 11/4/97, 12/98, 6/99, 8/99, 5/00, 8/00, 9/00, 10/01