PERMIT DOCUMENTS UNIVERSAL COUNTY-WIDE/MUNICIPAL FofaoFFrceusEonrLr
BUILDING PERMIT APPLICATION FORM FBC Version: (- Permit Type:
July 2013 Edition Accepted By: 1 S Application Date: I/f /60
Approved for use throughout Palm Beach County and Municipalities Application#:
A a
KIND of PERMIT(CHECK ONE): PROPERTY OWNER:DA(DEVELOPMENT
❑ PRIMARY PERMIT TENANT:
a SUB-PERMIT-If Fee&Value of a Sub-Permit are ADDRESS: . UNIT:
covered under a Primary Permit,complete boxes L 1 4,5,6 &
8 only to apply.If not covered under a Primary Permit, CITY: STATE: ZIP:
complete the entire application to apply. PHONE: FAX:
EMAIL: .
3 S
TRADE(CHECK ONE): PROJECT NAME:
o STRUCTURAL o ROOFING o ELECTRICAL pCN. 08 - 43 - 45 - 21 - 20 -.007 - 0010
o MECHANICAL a PLUMBING ID FIRE °GAS
El OTHER: LEGAL DESCRIPTION:HAPPY HOME HEIGHTS LT 1 BLK 7
PRIMARY PERMIT#: t /(n S( bra ADDRESS: 136 NE 12 AVE
CITY: BOYNTON BEACH
S
FURTHER WORK DESCRIPTION: REPLACE KITCHEN AND BATHROOM SINK. INSTALL WATER CLOSET. -
Type of Work: o New ❑Addition o Alteration I Repair ,o Demo o Temporary o Other
VALUE: 1,000.00 PERMIT FEE: NET S.F (for SFD's):
(SEE FEE SCHEDULE) IAS APPUES) (AS APPLIES)
g
EI OWNER BUILDER PER FL.ST.489(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2) .
e CONTRACTOR(CERT. HOLDER): NICHOLAS ZICARO III ' License#: CFC053936
DBA(COMPANY NAME): ZICARO'S PLUMBING SERVICES ' Contact Person: LISA .
ADDRESS: 2910 NW COMMERCE PARK DR - STE:7 CITY: BOYNTON BEACH STATE: FL . ZIP:33426
PHONE: 561-547-7103 FAY: 561-547-7104 EMAIL: INFO@ZICAROSPLUMBING.COM I
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.
Z I 0464
i5lanature of Owner or Atentl(Including contractor) i$lant4urt of Owner or Aleml(Including
Print Name: • Print Name: NICHOLAS ZICARO III
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
Sworn to(or affirmed)and subscribed before me this _. Sworn to(or affirmed)and subscribed before me this
day of 20 ,by day of 20 ,by .
/Name of person making statement] dume of
•
( person making statement)
(Signature of Notary Public-State of Florida) (Signature of Notary Public-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_OR Produced Identification
Type of Identification Produced Type of Identification Produced
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