PERMIT DOCUMENTS UNIVERSAL COUNTY-WIDE/MUNICIPAL FOR OFFICE USE ONLY
BUILDING PERMIT APPLICATION FORM FBC Version: Permit Type:
Accepted By: Application Date:
July 2013 Edition Application#:
Approved for use throughout Palm Beach County and Munidpalltles
KIND of PERMIT(CHECK ONE): PROPERTY OWNER:CONGRESS PROPERTIES
['PRIMARY PERMIT TENANT:VENDORNET
❑DSUB-PERMIT-N Fee&Value of a Sub-Permit are covered under a ADDRESS: 1903 S CONGRESS AVE#450 UNIT:_
Primary Permit,complete boxes 1,1 4.5.6 Al only to apply.If not BOYNTON BEACH FL 33426
covered under a Primary Permit,complete the entire application to Cf1Y: STATE: ZIP:
apply. PHONE: 561-742.6350 FAX:
EMAIL:
1 a
TRADE(CHECK ONE): PROJECT NAME:
❑STRUCTURAL [(ROOFING [(ELECTRICAL PCN: 084345:31-17-004-0000
El MECHANICAL [(PLUMBING (MIRE ❑GAS
❑ OTHER: LEGAL DEScRIPTION:WOOLBRIGHT PLAZA TRACT D
1903 S CONGRESS AVE �'
PRIMARY PERMIT 8: 15-4911
ADDRESS: 95-0
CITY: BOYNTON BEACH,FLORIDA 33426
FURTHER WORK DESCRIPTION: LOW VOLTAGE ON REMODEL
Type of work flew ❑Addition �Aheration ❑Repair ❑Demo Demean ❑other
VALUE: 'S—�n 00 PERMIT FEE: NET S.F(for SFD's):
mg m SOMME) (AS&ovum1 (AS AMMO
a
❑ OWNER BUILDER PER FL ST.489(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2)
❑� CONTRACTOR(CERT.HOLDER): JOSEPH P BOTTA Ucense ft: EC-13002513
DBA(COMPANY NAME): CONTACT ELECTRIC Contact Person: LAURIE ROSE
ADDRESS: 7663 2ND TERRACE STE: CITY:LAKE WORTH STATE: FLORIA ZIP:33463
PHONE: 561-969-7731 FAX: 561.969-1702 EMAIL: LAURIEOCONTACTELECTRIC.COM
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 CONDITIONERS,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 laws regulating construction and toning.2
gimn,It oral,,..elf yIl�whq=Maw
alrw�.wi•wl
print Name: print Namg: JOSEPH P BOTTA
NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/ NOTARY REQUIRED IF S 2,500 OR MORE,OR FOR ALL OWNER/
BUILDERS REGARDLESS OF$VALUE STATE OF FLORIDA BUILDERS REGARDLESS OF$VALUE STATE OF FLORIDA
COUNTY OF COUNTY OF PAW BEACH
Sworn to(or affirmed)and subscribed before me this Sworn
too(or affirmed)and subscribed before me this r# day
day of , 20 ,by /2rt"0/2 20 16 ,by
JOSEPH P BOTTA
Pim d pava,-uMbrmmTWA I. V+-„o dpeao„eWYa Ntemen}
/��r/
(Signature of Notary Public-State of Florida) I nature of• • r • - • c-State of Florida)
(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 X OR Produced Identification
Type of Identification Produced Type of identification Produced
Page l of 2
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