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PERMIT DOCUMENTSr ~~ CITY OF BOYNTON BE~4CH ,, ~ ~ ' .( DEVELOPMENT DEPARTMENT BUILDING DIVISION ~~J~~/~ D ~~°' ~ 100 East Boynton Beach Boulevard • Boynton Beach, FL 33435 • (561)742-6350 • Fax (561)742-6357 PERMIT APPLICATION FORM Permit No. F.B.C. Version ~ Accepted by Application Dat APPLICATION INFORMATION .. GEN: CONTRACTOR 8- DESIGNER INF A ION. . .. . . _. _ Owner's Name o~~ ~~~ ~©'9 ^ Gheck if Owner/Builder (Attach O/B Prerequisite Form Address 9` 3' ~ ~ Contractor License No, ~(~J ~ ~J~~ Q Cit '`' y.~ .~~~~ State,~_ Zi~~ Y~~ ~ ' Compan `~ ,,n ~~~ Home Phone (~~') ' 3 ~ ~~ ~,~ ~ ~ Address%/ ~~ -1~' ~ /.~~''p~ t.,~ Cell Phone ( ) City ~ ~~Gf~~ State Zip,~~~ Fax No. ( ) Phone ;~~) ~~',~ ~c~~" Fax (~`Sr~ ~?~ J'~t'~. PROPOSED IMPROVEMENT LOCATION Email Address9f Improvement Architect /Engineer's Name Address ~~ Subdivision / Block y L ~~ Lot /ate/ City (cif ~ State Zip Phone ( ) PCN # ~ ~ ~ Email /,~ ,~ Project Name ~® ~ ~t2~nn~ U ADDITIONAL'INFORMATION ~~. ~~. , . Fee Simple Title Holder (if other than owner) _ ~~~~ ~~ V Address ~ City State Zip Mortgage Lender Bonding Company Address Address City State ~ Zip City State Zip ., ... : DESCRIPTION OFPR SED IMPROVEMENTS Description of the proposed work: ~~~ ~ e~ i~~i~~ ~~~% ?r ~ G~ 1 Type of Work New ^ Addition ^ Alteration ^ Repair ^ Demo ^ Temporary ^ Other Proposed Work structural ^ Electrical ^ Plumbing ^ Mechanical ^ Roof ^ Fire ^ Gas ^ Other Current Use or Occupancy Is this a Change in the Use or Occupancy? ^'Yes ^ No STRU URE INFORMATION Type of Construction ^ I-A ^ I-B I-A ~ II-B ^ III-A ^ III-B ^ IV ^ V-A ^ V-B Total Sq. Ft. Building Height No. of Units Stories _~ Is the building served with an automatic fire sprinkler system? ^ Yes ^ No - PERMIT FEE - - Jo"b~F~t~as~rt~on.~~(,i g$ ~ C./ x 0.023 = permit fee of $ ~ `j ~f ~~~ - ct)(,, a"~d'rr:' ~ . lei; ,~., ;_,.~:. vide c s~+BR/rent~iay•be asked to pro py of a signed contract to determine job value. ($46.00 Minimum) ~ ~~1~~ C ( f ~7 f6~ !'~,i.f ! F,F ~ Y ^` r ~~1.~ y /S. { ~~ ~ iii ~~ e(t({v ~~ 'r~ ~ K ~ ` ~. .~ ~ - ~~!! }} t {~.4Uti \11.~ ~ n~ta%~~Fr:,s:(t~ )y y ri v +7 y , --_ _. u~uij1 ;I S:\Development\BUILDING\Forms-Templates-Signs\Permit Application.doc Revised 10/23/07.,,711/08, 2/2/09 Page 1 of 4