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 Municipalities
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KIND of PERMIT(CHECK ONE): PROPERTY OWNER:G&I VIII MEADOWS SQUARE LLC
DPRIMARY PERMIT TENANT:
❑� SUB-PERMIT-If Fee&Value of a Sub-Permit are covered under a ADDRESS: C/O DRA ADCISORS,LLC 220 EAST 42ND STREET UNIT:'mHLOOR
Primary Permit,complete boxes 1.,1 4.5,6 &B only to apply.If not NEW YORKNY 10017
covered under a Primary Permit,complete the entire application to CITY: STATE: ZIP:
only. PHONE: 561-989-2240 FAX:561-361-8703
EMAIL:
1 s
TRADE(CHECK ONE): PROJECT NAME: HOME AWAY FROM HOME ACADEMY
['STRUCTURAL ❑ROOFING ['ELECTRICAL PCN: 08434507030200032 -o MECHANICAL ['PLUMBING ❑FIRE ❑GAS
OTHER: LEGAL DESCRIPTION:
PRIMARY PERMIT#: 16-0305 ADDRESS: 4791 N.CONGRESS AVE
CITY: BOYNTON BEACH,FL 33426
FURTHER WORK DESCRIPTION:
Type of Work:ID4ew Addition ['Alteration ERepair Demo OTemporary ['Other
VALUE: PERMIT FEE: NET S.F(for SFD's):
(SEE FEESOIEDULE) (AS APPOES) (AS APPLIES)
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❑ OWNER BUILDER PER FL.ST.489(AS NAMED ABOVE, FOR CONTACT INFORMATION SEE BOX 2)
❑✓ CONTRACTOR(CERT.HOLDER): ROBERT LUDLUM License#: CFC057526
DBA(COMPANY NAME): Aqua Dimensions Plumbing Servigg Contact Person: Rob Marlin
ADDRESS: 1651 SW MACEDO BLVD STE: CITY:PORT ST LUCIE STATE: FL ZIP:3498
PHONE: 772-344-8433 FAX: 772-343-7418 EMAIL: adps@aquadimensions.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 accurat d that all work will be done in compliance with all
applicable laws regulating construction and zoning.
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-
(Nenatore of Owner or Menu(Induding contractor)
Print Name: Print Name: ROBERT LUDLUM
NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/ NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/
BUILDERS REGARDLESS OF$VALUE STATE OF FLORIDA BUILDERS REGARDLESS OF$VALUE STATE OF FLORIDA
COUNTY OF COUNTY OF ST.LUCIE
Sworn to(or affirmed)and subscribed before me this Sworn to(or affirmed)and subscribed before me this 12TH day
day Of 20 -by of APRIL 20 16 by
ROBERT LUDLUM
(Name of person making statement). (Name of person making statement).
haTirio
(Signature of Notary Public-State of Florida) (Signature of Notary P lic-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
RHONDA LAFFERTY Page 1 of 2
• 11 MY COMMISSION#EE854297
,f▪ ah , EXPIRES January 08,2017
(407)i398-0153 FlondallotaryServ¢o corn