BCP2010-06602City of Clearwater
Develo ment & Nei hborhood Services De rtment
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,.. 100 S. Myrtle Avenue, Suite 210
Clearwater, FL 33756
Telephone: (727) 562-4567 Fax: (727) 562-4576
www.mydearwater.com
BUILDING PERMIT APPLICATION
PARCEL NUMBER 0 z' 57 7 /!1/ p 00
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PROJECT/JOB NAME I ???
PROJECT
LOCATION PROJECT ADDRESS ZIP 1r7? 1
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BUSINESS NAME PHONE
LEGAL DESCRIPTION OF PROPERTY
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PROPERTY PROPERTY OWNER NAME ,7 11` e 7
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ADDRESS 1l?c ^ l ?^^
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phone
CITY cZe a1`r r-
STATE l" l ZIP 3 3? v
number)
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PHON
E FAX
NAME
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ARCHITECT/
ADDRESS
ENGINEER
CITY STATE ZIP
PHONE FAX I Office Only
E-mail:
NAME OF COMPANY `S-- &-
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LIC. HOLDER CaC X PHONE
CONTRACTOR
(Please print ADDRESS FAX l? l ZG2 j
clearly) CITY STATE ZIP
STATE LICENSE # G ?CG :?3 9-5'-4;cCLB # I ? o
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E-mail: j 00
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EXISTING BUILDING USE J PROPOSED BUILDING USE '- s
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GENERAL NUMBER OF STORIES BUILDING HEIGHT NUMBER OF UNITS?_
PROPERTY'
INFORMATION CONSTRUCTION TYPE: 1 II III IV V VI; P OR U
SQUARE FOOTAGE: LIVING COMMERCIAL I
ARAGE ARPORT OTHER TOTAL 'Office Only
PLEASEF/LL OUTBACKPAGE-APPL/CAT/ONMUSTBECOMPLETE - _..._..._..._....._..._._...... _.._...__........ _...._........ _:
IF FAX PERMIT, PLEASE ENTER PROPERTY ADDRESS HERE:
__._._...__._..__..._._..----_....._._...._.._._.__....... ......_...___..._..................... ....... ..._____.__.__..._._......._....._..._._....__._.._._..___..__.__._................ ....................-_..__.._........._._....-----....._.___..._._....._.____..? ?____ ._.....?
PROJECT DESCRIPTION:
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NATURE
OF WORK
(CHECK
ALL THAT
APPLY)
?BUILDING
?MECHANICAL
?ROOFING
?LANDSCAPING
?TRAFFIC OPERATIONS
?ELECTRIC
?GAS
?ENGINEERING
?UTILITIES
?CLEARING & GRUBBING
JDPLU RING
?FIRE
?LAND RESOURCES
?NEAR WETLANDS
?OTHER
TYPE OF WORK: ?NEW ?ADDITION ?REMODEL OREPAIR ?DEMOLITION ?OTHER
VALUATION: $ (THIS MUST BE FILLED IN, PLEASE PRINT CLEARLY)
BOARD REVIEW REQUIRED: ? DRC DATE: CASE (circle one): FL OR FLS #
?CDB DATE: ?APPROVED ?DENIED
Anyone planning to do excavation work, must notify the one-call "CALL SUNSHINE" Notification Center at 1-800-432-4770 prior to any
excavation work being done, in order to prevent underground damage. Federal D.O.T. Regulation Part 192, Sections 192.614 and 192.707.
Application is hereby made to obtain a permit to do the work and installation 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.
CERTIFICATION:
I HAVE COMPLIED WITH ALL THE FEDERAL, STATE AND LOCAL ASBESTOS REGULATIONS CONCERNING NOTIFICATION OF THE
PROPER AUTHORITIES OF THE PROPOSED DEMOLITION AND RENOVATION PROJECTS.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY.
IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
I am aware of Florida and Federal Accessibility Codes, and I certify that I have met the requirements of both.
I certify that, this application together with any plans submitted is accurate and represents all work being done at this time. All work will be done
in compliance with all applicable laws regulating construction and zoning and if not I realize 1 am responsible for the removal of any construction
in violation of these laws or regulations. Any deviation from information submitted, unless approved by the Building Official will render this
permit null and void.
IS THIS APPLICATION THE RESULT OF A STOP WORK ORDER OR NOTICE OF VIOLATION? YES_N(l X
PAYMENT METHOD: ? CASH ?CHECK ? CREDIT CARD - If paying by credit card include authorization form.
Slgnature ofLloense Hold rORAudh Pelwnnel Date
Please Print Name Here / Tide In flan orH weer