PERMIT DOCUMENTS NOIS1fkti0 �aif�
.,T, tl�,, , OFFICE USE ONLY
CITY OF BOYNTON 6j'?GH tu• ; REV /
DEVELOPMENT DEPART DENT Vd416-DG l DIVISION
��. q 100 Col Boynton Brach Router/IrakchrFrs33425•(561)742-6350•Fa%742-6357
PERMIT REVISION APPLICATION
NOTICE: This revision application must bear the signature of the primary contractor. If
the scope of work is increasing to include a trade not shown on the original plans, the
corresponding subcontractor's signature is also required. i
THIS REVISION IS FOR iji. Changes to Plans 0 Additional Work
,
Permit If \(P -V50'1 Project Name Wo\rnora- U o of 6 tett)
Job Addressj S , Rctera.l -I-fW,..I 1I , 'yl-1{cn (3each , 1Z I Unit#
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Primary Contractor (or Owner/Builder)? pQnSITU,(4ixn I License No.
Address pj1/4055 Spetwt ng (200A �13 I City, State,Zip b j€,Jsh t k. J_3J-�l0 1
Contact Name "t' Phone Email
Subcontractor Name(ii applicable) Vex(one TYe. 2(alcc.-lion License No,Fi _ ‘;-03,301/4-
Address rk)(60.1, Ic 2Us City, State,Zip ta(nR1 r i t. j 3%kp19
Contact Name Il' ant el `firNr1e Phone 712) 1202 a1'12 Email
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Description of Proposed Revision
Trades Affected (check all that apply): ❑ Building 0 Roofing 0 Electrical
0 Mechanical ❑ Plumbing 0 Gas a Fire Protection 0 Other:
Value of Proposed Revision Revision Fee(office use only)
NOTE: Revision Fee= Value of Proposed Revision x 0.023, or$75 + $10 per page, whichever is greater.
t' I, the undersigned, am applying for a revision to the approved plans as Indicated on the accompanying construction
F.1
o ct a, ' documents. I understand that it is my responsibility to have the approved construction docum i or inspection.
ga a-rz $ #
Q o a I Primary Contracfw'sSignawre Subcontractor's Signature
g 2 :: LL (Notaryrequired if value exceeds$2,500.
< r e e9 ) (NotayrequudlliatJeexceeds$2500.)
n : ) STATE OF ,COUNTY OF STATE OF FOri JC& ,COUNTY OF 441-1\S\a2 \\
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s E 0 8z, The following instrument was acknowledged beton me this The following instrument was acknowledged before me this
z i m day of ,20 3 day of Ppr11 ,20 Cl
•••^•...,„, , by (pill signors name), by rYlanuc-\ 'T -.etor' (pintsioner'sname),
tfr` ria 1 who is personally known to me or who has produced_ who is personally known to me or who has induced
a- as identification,and who did J did not take an oath. as idenlificabon,and who did I did not lake an oath.
LNotary's Signature.Printed Name&Seal ca/ltNotary s S Signature,Printed Name 8 Seal
5:\Development\euaDIUG\ro,ms-TempIates.5igns\Permit Revision Applicationdor,
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