PERMIT DOCUMENTS UNIVERSAL COUNTY-WIDE/MUNICIPAL UtyAs( JUlP U
BUILDING PERMIT APPLICATION FORM FBC Version: I'_- Pe&'mitfype?
July 2013 Edition • Accepted By: ;Oltlit;L I Application
1 ILtt cur
Approved for use throughout Palm Beach County and Municipalities Application It: RI iii rvis r t"t9S1^t,I
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KIND of PERMIT(CHECK ONE): PROPERTY OWNER:
❑PRIMARYPERMIT TENANT: 0017bIry Gaya/Pi
.p/UB-PERMIT-If Fee&Value of a Sub-Permit are ADDRESS: 34171 g -;4-- S4 y 4/Vet UNIT: !D V.
covered under a Primary Permit,complete boxes b 4y,_6 & CITY: hST)G./ 9/107 /iaED� STATE: �K ZIP: ?3 Lt i f
8 only to apply.If not covered under a Primary Permit, g
complete the entire application to apply. PHONE: ti"( ttS Ia '_-5-3 FAX:
EMAIL:
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TRADE(CHECK ONE): � PROJECT NAME: /?4N BO cei-a41 q.&
o STRUCTURAL ❑ROOFING „ELECTRICAL PCN: E E. Cel- Kt-L11 7-
2 6' 0 C. C 8_7 Z
o MECHANICAL o PLUMBING ❑FIRE ❑GAS ?
❑ OTHER: LEGAL DESCRIPTION: ,/.,
PRIMARY PERMIT#: /6 —OoaO/93 y ADDRESS (0 I f{�`& ��`
CITY: /C t-fit. v>~ 'az„ G
FURTHER WORK DESCRIPTION: ( Vj`2cq. /me` e ` 'fiot-e 4 ! V
Type of Work: o New o Addition NSIteration o Repair o Demo o Temporary o Other
VALUE: 3491' PERMIT FEE: NET S.F(for SFD's):
(SEE FEE SCHEDULE) IAS APPLIES) (ASAPPLIES)
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Ei OWNER BUILDER PER FL.ST.489(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2)
o CONTRACTOR(CERT. HOLDER): SFr C/a-C-7'029"-C- /J'C. _ License#: 6-61/500.7-7y 22
DBA(COMPANY NAME): Contact Person:?CAen•.f Wt .
ADDRESS: r'O Nei /5-6 Sf. STE: CITY: ,('(.Dirt/ STATE: /CG ZIP: 3'7/69
PHONE: 4,,r1-417- e B4 0 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 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 zoning.
(Signature of Own or Agent)(In g contractor) (Signature of Owner or Menn(including contra-.,
Print Name: we, .Q eui3 Print Name: / 4 • n !ti A- J A
NOTAR EQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/ NOTARY REQUIRED IF ,500 OR MORE,OR OR ALL OWNER/
BUILDERS R DLESS F$VALUE STATE OF FLORIDA BUILDERS RDLESS OF VAI E STATE OF FLORIDA
COUNTY OF 1 g COUNTY OF
Sw• •• (or affirm:•)and subscrib d before me this `1 Swor r a rme, and subscribed before me this
day o"1 �•, • ..A,it 20 � .by day of��s •A 20 VP ,by 1
.ate, m •
/ ���1 ( .me:— m.n rutemm VIP)
ir-1
(Signature .'• . VC 0$31Biik d3fBFkbFFW0125 (Signature o SF't'T' orrt."7 . ,
(Print,Type : = !,J:o blic) JOSEPH
(Print,Type,or ... ggen4 W9tP&taKti )
Personally ,: 4 s g�•.. ._.: :,. : Personally Kn. :,...•14.::R giitte bid MWthe %W
Type of Identification Produced . .L.on
Type of Identi .. -i•.• ..• . .
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FEE SIMPLE TITLEHOLDER,BONDING COMPANY,ARCHITECT/ENGINEER AND MORTGAGE LENDER INFO IS REQUIRED WHEN THE
AGGREGATE VALUE(TOTAL COST OF ALL IMPROVEMENTS&NOT JUST WORK AUTHORIZED BY THE INDIVIDUAL PERMIT)IS$2,500 OR
MORE(EXCEPT HVAC REPAIR/REPLACEMENT<$7500).PLEASE ADDRESS ALL ITEMS.
2
Fee Simple Titleholdet's Name of other than owner): Bonding Company:
Fee Simple Titleholder's Address of other than owner): Bonding Company Address:
City: State:_Zip: City: State: Zip:
o Same as Owner o Not Applicable
-- -
Architect/Engineer's Name: Mortgage Lender's Name:
Architect/Engineer's Name Address: Mortgage Lender's Address: _
City: State: Zip: City: State: Zip:
o Not Applicable o Not Applicable
WARNING TO OWNER:
YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO
YOUR PROPERTY.A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION.
NOTICE TO CONTRACTOR: FOR A DIRECT CONTRACT GREATER THAN$2,500(EXCEPT FOR HVAC SYSTEM REPAIR OR
REPLACEMENT LESS THAN$7500), FLORIDA STATUTES REQUIRE THE APPLICANT TO FILE WITH THE ISSUING AUTHORITY,
PRIOR TO THE FIRST INSPECTION,EITHER A CERTIFIED COPY OF THE RECORDED(BY OWNER) NOTICE OF COMMENCEMENT
OR A NOTARIZED STATEMENT(BY OWNER)THAT THE NOTICE OF COMMENCEMENT HAS BEEN FILED FOR RECORDING,
ALONG WITH A COPY THEREOF. IN THE ABSENCE OF A CERTIFIED COPY OF THE RECORDED NOTICE OF COMMENCEMENT,
NO SUBSEQUENT INSPECTIONS CAN BE PERFORMED UNTIL THE APPLICANT FILES SUCH CERTIFIED COPY WITH THE ISSUING
AUTHORITY.THE CERTIFIED COPY OF THE NOTICE OF COMMENCEMENT MUST CONTAIN THE NAME AND ADDRESS OF THE
OWNER,THE NAME AND ADDRESS OF THE CONTRACTOR,AND THE LOCATION OR ADDRESS OF THE PROPERTY BEING
IMPROVED.
IF YOU INTEND TO OBTAIN FINANCING,CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR
RECORDING YOUR NOTICE OF COMMENCEMENT.
OFFICE USE ONLY BELOW THIS LINE
I
CODE EDITION/NOTES: USE(CHECK ONE):
o 1&2 FAMILY ❑TOWNHOUSE ❑CONDOMINIUM
o MULTI-FAMILY o COMMERCIAL o INDUSTRIAL
o AGRICULTURAL-BLDG CODE EXEMPT o OTHER:
o USE CHANGE:
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APPROVED BY: • DATE:
Permit Officer 5; : ;I'i:•L ::I':':.: s..
AUTHORIZED FOR CERTIFICATE OF OCCUPANCY: - • - DATE: - a•
,.).
Building Official or Designee - -
AUTHORIZED FOR CERTIFICATE OF COMPLETION: .• - - ""' "" '•DATE: — - - -
_Bunging Official or Designee
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