PERMIT DOCUMENTS UNIVERSAL COUNTY-WIDE/MUNICIPAL �FrOROFFICEUSEONLY /
BUILDING PERMIT APPLICATION FORM FBC Version: %/ / Permit Type: Ji
July 2013 Edition
Accepted By: p;ion Date /� ,Approved for use throughout Palm Beach County and Municipalities Application II: I/
KIND of PERMIT(CHECK ONE): PROPERTY.QWNER.The Women's Circle, Inc.
I PRIMARY PERMIT TENANT: 'ne WOTrlell s Circle
❑SUB-PERMIT-If Fee&value of a Sub-Permit are ADDRESS: 912 SE 4th Street UNIT:
covered under a Primary Permit,complete boxes L 3 4,5,6 & Bo Boynton Beach FI 33435
8 only to apply.If not covered under a Primary Permit, CITY. y STATE: ZIP:
complete the entire application to apply. PHONE: 561-244-7627 FAX:
EMAIL:hWalIISgWOmensclrcie.Org womclrC9iaol.com
t a
TRADE (CHECK ONE): PROJECT NAME: Parking Lot, Wall, Lighting, Landscape ar
A STRUCTURAL o ROOFING a ELECTRICALPCN: 08 - 43 - 45 - 28 _ 00 000 _ 5070
o MECHANICAL ❑PLUMBING ❑FIRE o GAS
S OTHER: Paving, Grading, Drainage, Lan LEGAL DESCRIPTION:
ADDRESS: 918 SE 4th Street
PRIMARY PERMIT ft: CITY: Idoymori BeadICFKsrtfl
f !� /�
FURTHER WORK DESCRIPTION: r Autn 5 i 4rpym>--3 .F LD2w,.,9- +E._ $.3c.w eFq¢Kliik= A Lo A'S c •
Type of Work: o New o Additionioo Alteration o Repair I Demo o Temporary o Other 3
00
VALUE: ( "4IpcpE MR IT FEE NET S.F(for SFD's): SEP 10
ISEE FEE SCHEDULE) (AS APPLIES) (AS APPLIES
k aits S 10/�
0 OWNER BUILDER PER FL.ST.489(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2) eUfCOJNr, 0
C CONTRACTOR(CERT.HOLDER): Thomas Falls License ft: CBC044614OJVia aV
DBA(COMPA.11gNpNMWE). TF Construction ManagementSEServil contactperson: Tom Falls
ADDRESS: " ' "" `Stree( 5b1 t3U/ Sy Cm.Boca onSTATE- Ft ZIP:`�_r
PHONE: 561 FAX: EMAIL:
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 COND111ONERS,etc.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate nd that all work will be done in compliance
with all applicable laws regulating construction and zoning.
r
nor c i .r /./ ovrn c.
I reof o nt (including contractors' i SI:•.• . 1 • r• :.=u 1 ng wrmacmr)
Print Name: Lorraine Ryan MMS print Name: Th•mas ails
NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/ NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/
BUILDERS REGS OF SymuE STATE OF FLORIDA BUILDERS REGARDLESS OF$VALUE STATE OF FLORIDA
COUNTY OF /A tedoci> COUNTY OF FA-a M ---. C'J -c P/
Sworn to affirmed)and subscribed before me this =294-- Sworn to or affirmed)and subscribed before me this J2—
day of t _ 0 by day of ace pd-> , 201 9' ,by
Ade ./ . . :, /n-MS • MA-5 —19-ILS
'.me• person ma, cowmen Ir!—meld person mtem
(Signature o Notary Public-State of Florida) (Signature of N. -ry Publl State of F f da)
(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 V OR Produced Identification
Type of Identification Produced Type of Id - y — — — —�t
WUS y
THFAFRAA.IAr:ImnN •�o s KATHY D.LYNCH
: t MY COMMISSION C FF 028459 ( l, Notary Public-State of Florida I Page 1 of 2
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•` EXPIRES:Jury 1,2017 1 ` r. ire MyComm.Ex
'2A h° ' Banded rnmew,PuwSuaseadmt ••; ,; pires Jun 2.2018 I
4 7•,,; .•' Commission •FF 096916 0