PERMIT DOCUMENTS a_, it ,
liN
� CITY OF BOYNTON BEACH
DEVELOPMENT DEPARTMENT I BUILDING DIVISION
oy 100 East Boynton Beach Boulevard•Boynton Beach,FL 33425•(561)742-6350•Fax 742-6357
4.7.0 hi OF.
ELECTRICAL POWER RELEASE REQUEST
NEW 1- & 2-FAMILY DWELLING / 2-STORY TOWNHOME
FEE $150.00
Project Name Aspen Glen Permit No. /3 _ ct a &>
Job Address 3b2,0 Aspen Leaf Drive
Type of Building SFR
This is a request for a 30-day temporary power authorization to allow contractors to test systems,
equipment and appliances in a one- or two-family dwelling or townhome prior to the issuance of
the Certificate of Occupancy. Section 112.2 of the Boynton Beach Administrative Amendments
to the 2010 Florida Building Code allows the Building Official to authorize the temporary
connection of the building or system to the utility source of energy, fuel or power for the purpose
oftesting building service systems or for the use under a Temporary Certificate of Occupancy.
NOTE: This document must bear the notarized signatures of the General Contractor and the
Electrical Contractor. Occupancy of the building by the general public prior to receiving the
Certificate of Occupancy will not be allowed. This property remains a construction site until the
required Certificate of Occupancy is issued. The City of Boynton Beach retains the right to
,revoke this permission at any time for any reason. . . . _
FOR OFFICE USE ONLY
Date Paid /MV Receipt No. Electrical Final Approved Date
Reviewed by( aloftloft X pe 4-f, Review Date
I hereby certify the following:
• The electrical system is complete and a final electrical inspection is approved.
• ! All required light fixtures, HVAC equipment and fixed appliances are installed and
connected.
• We hold the City of Boynton Beach harmless in the event of any accident or damage to
life or property.
• We waive the right to appeal to the Public Service Commission.
• The Certificate of Occupancy will be acquired within 30 days or power will be
voluntarily disconnected.
(Continued on other side)
1-11
ELECTRICAL POWER RELEASE REQUEST (Continued)
Randy Sjaardema , being first duly sworn, depose and say that I am the Electrical
Contractor for the above described property and that the electrical installations as now existing will not
create a safety hazard if t orary service is connected. I certify that the above statements are true and
correct.
I 'DA-14
.'Electrical Contractor or uthorized Agent Date
Electrical Contractor License# E00002938 Electrical Contractor Phone# 561-586-6499
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this 1461-I'4 (date)
by Randy Sjaardema , who is personally known to me or who has produced
(type of identification) as identification and who did/did not take an oath.
(SEAL)
Signature of person taking acknowledgement JW. ke_sttrocnlrsrRnpN
Name of officer taking acknowledgement(typed, printed or stamped) ,,z: ,; MY COMMISSION AEE038068
Title or rank Serial number, if any - • ExPISEs:Februa720;2015�
••Pa—C
I, Phil Serrate , being first duly sworn, depose and say that I am the General
Contractor of the above described property and that I will not permit occupancy of this building until final
tc: s iinspections have..been called for and approved and a Certificate of Occupancy-is,issued by the Building
Division, and that I hay: the authority insofar as the owner of said property is concerned to prohibit
occupancy until such fi :l inspections are obtained. I certify that the above statements are true and
correct.
21slr-
General Contract 4 •r Authorized Agent Date
•
General Contractor License • GCG062343 General Contractor Phone# 305-559-1951
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this '2-1 s I I y (date)
by Phil Serrate , who is personally known to me or who has produced
(type of identification) as identification and who did/did not take an oath.
MY COMMISSION gEE00fi640
XPIRES:November 4,2014
Signature of person taking acknowledgement �• l .�a•° a ..M . - - lers
Name of officer taking acknowledgement(typed, printed or stamped
Title or rank Serial number, if any