PERMIT DOCUMENTS a.
,UNIVERSAL COUNTY-WIDE/MUNICIPAL FOR OFFICE USE ONLY
BUILDING PERMIT APPLICATION FORM FBC Version: Permit Type:
July 2013 Edition Accepted By: Application Date:
Approved for use throughout Palm Beach County and Municipalities Application#:
4 4 /1 p
KIND of PERMIT(CHECK ONE): PROPERTY OWNER: acroI F ( l n ne
•
❑ PRIMARY PERMIT TENANT: � ,.
o SUB-PERMIT-If Fee&Value of a Sub-Permit are ADDRESS: /a//W 13 c' n u.50tt-1 hjEt
covered under a Primary Permit,complete boxes 1.,a,445,_6 & CITY: •
Q_ / ZIP .
8 only to apply.If not covered under a Primary Permit, (�-�t•/) �`(� Ge' STATE: FC-ZIP: 7 3 t
Y
complete the entire application to apply. PHONE: ` FAX:
EMAIL:
I I.
TRADE(CHECK ONE): PROJECT NAME:, /
o STRUCTURAL ❑ROOFING �IELECTRICAL PCN: r/ S(-43 1( •3Q- )0/2a D L J 'L)
o MECHANICAL ❑ PLUMBING /❑FIRE o GAS
o OTHER: �- LEGAL DESCRIPTION: 1-01 P5 0 � T/neH VI'1 rdid-l��
PRIMARY PERMIT St: ) 1 —I /37 ADDRESS: /c- & U I L Ljivc ('1 ('cif
CITY: at — • t ► -:Pt i C
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FURTHER WORK DESCRIPTION:
Type of Work: o New o Addition o Alteration Repair o Demo o Temporary o Other
VALUE: PERMIT FEE: ET S.F(for SFD's):
)SEE FEE SCHEDULE) (AS APPLIES , (AS APPLIES(
e
0 OWNER BUILDER PER FL.ST.489 NAMED ABOVF.FORR CONTACT INFORMATION SEE BOX 2) _
o CONTRACTOR(CERT. HOLDER : ilea/ ,/}2-e r/— Lice ee it la��
A.
DBA(COMPANY NAME): %;t.-,i' / _ . - • ' #' tact Person: )Lc taia Q!' = 7r
ADDRESS: .,; a STE: a CI : /i79-,'447c STATE: C. ZIP:?766-
PHONE:`/ 3 % 3 ' 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 Co DITIONERS,etc.
OWNER'S AFFIDAVIT: I certify that al the foregoing information is ac that-all f k will be done in compliance
with all�.r able laws regul. '• v i-struction and zoning. ��G .
•
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_ _/ al e.%� I MOM
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.tore of. •• •r entt ding contract
Print Name: 4 iJJIi 7 . '` ' Print Name:8/}-iv/✓/G[et . r.'
NOTARY REQUIRED IF$2,500 OR MORE,OR FO• 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 P I 4/1'1 e
Sworn to(or affirmed)an subscrib dp nefore me this Sworn to(or affi med)and ubscribed b f re me this ay
day of 20 +{' ,by day of onk a 20 ,by t
k• =tiw - nYVe r.C(
)Name of person making statement)
ram..
'ame per.
•NePpold
s Loa'g l Nenue(•821:11.:1X3
X3 tea
(Signature of Notary Public-State of Florida) (Signature of Notary PQ%ic-r7e..- e1pIo tl �0atl <1....#
o 3
(Print,Type,or Stamp Commissioned Name of Notary Public)
(Print,Type,or Stam• e vone.lVa
Personally Known_OR Produced Identification Personally Known tificatf0�
Type of Identification Produced Type of Identificati ry Ut ,ecRADOSLAV TEMELKOSKI
_i •1 MV COMMISSION#FF083889
Vq Tis% EXPIRES January 15.2wa of 2
X4o71398.o153 FlorldallotaryServlce com 'age
o`0° City of Boynton Beach
1 (9 - 435
, ,
Building Division
CHANGE OF CONTRACTOR
"411/1)/(±C-
�_ � CONTRACTORfnv_ - JJ�� '^�
• Know all men by these presents that I, Lr f/l/()!Lt L- A l'2 E7T , for bi-/2,e � 1:46Z aC 41
have been contracted by �d-.n/ 7 (9uQali(i�) (company name- identical(to license) W
4�A7(UN to complete the ,��c.7n,�GrN� ri�1T/a/..,G7�
//;; (p�perty own`er�nvie) (describe work)
construction at 1 7C' JOc"r�1Z>I'1 ti-coot (,/ Jt Ie and agree to assume the responsibility for the work
(property location)
being done there, consistent with the plans and associated documents for Berms • 1 1- V 2 7 C and certify that all
w�/oprk will comply with the codes and ordinances of the City of Boynton :•�.upon•the y4mpletion % the project. -
Ot�dditi.h pR-RR,� ' . " �
Qualifiers name (printed) *Taffies-an. .th -
STATE OF FLORIDA, COUNTY OF S+- k--‘'C i
The foregoing instrume was acknowledged before me_�his— -,2 S-- / (7
t (date) by
<<^ `r/e, o personally known to me or who has produced
( • • '•-•n - • - .tde.,acation and who did (did not)take an oath.
*°-,,,liz7.. RADOSLAV TEMELKOSKI (SEAL)
Signature of person taking acknowledgment �, `T. 1•) MV COMMISSION OFF083889
Name of officer takin acknowledgment-typed, printed or stamped ',..!,166,.•./,, EXPIRES January 16,2018
�•....( (407)seJ55 is Fl: Icll ty ry :rvlta.cdn —.
Title Of tank V /C1 Send' 1, rdNo
C OWNER
I, Gk co II C/ Tb I e rug e do hereby
�certify that I am th:` ner's agent of the above referenced
(ProPe7J(�}y �y 99r/owner-Smell �v/�f(/ ( J
property ( I����jjjjjjjjjj s SV ) and do hereby hold harmless and release the City of Boynton
(property control number)
City of Boynton Beach of any and all liability arising from the transfer of the building permit(s)to the contractor mentioned
above. I certify that the above referenced contractor is my lawful agent empowered to complete the above referenced
construction work. /
Cot COI ? + e✓4 n P �//�(/J/
Owner's name (printed) Owner's�signatJ �e��
STATE OF FLORIDA, COUNTY OF (,(/ ( e //�
The foregoing instrument was acknowledged before me •- // (date) by
1 • • e 1 S , who ' personally know me "or who has produced
(type of idents Ica • . '. and who did (did not)take an oath.
i (SEAL)
Signature of person taking acknowledgment p. _sem-414, , t EI.KOSKI
Name of officer taking acknowledgment-typed, printed ors amped irkraMi f rnMMISSION OFF083689
Title or rank / II .ir— r _ 1t i: lgya4ffiH ' •
. (40 3950153 FIOrICSNOt-
100 East Boynton Beach Blvd,PO Box 310, Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax: (561)742-6357
S:IDevelopmenttBuilding1FormS TemplatestChange of Contractor (1/00,8/00,12/02,1/03,3/03)