BCP2010-10229tL
Planning & Development Department
Clearwater 100 S. Myrtle Avenue, Suite 210
Clearwater, FL 33756
BUILDING PERMIT APPLICATION 567 Fax: (727) 562-4576
www.myc%arwater:com
PARCEL NUMBER
PROJECT/JOB NAME S,S ?- (j hd mac,, f e-f M'p fl-- 6- H01 S'c
PROJECT
LOCATION
PROJECT ADDRESS 9 a?a d Ll,__ F- 337 6P
ZIP
BUSINESS NAME tJ'11? PHONE a'R( 1;1?
LEGAL DESCRIPTION OF PROPERTY
?? b ?? Y ?/ Le ??
1
PROPERTY OWNER NAME 1
PROPERTY O? i
G
OWNER ADDRESS / 0 r
(must have
h _
FL ZIP
337 SOS
p
one CITY STATE
number) _7a7-
PHONE
FAX
NAME
ARCHITECT/ ADDRESS
ENGINEER
CITY STATE ZIP
PHONE FAX
E-mail:
NAME OF COMPANY
LIC. HOLDER PHONE 2 7d'
CONTRACTOR
ADDRESS FAX
(please print
clearly) CITY STATE ZIP
STATE LICENSE # PCCLB #
Contractor E-mail:
Contact for this project e-mail:
N
om
EXISTING BUILDING USE ( s? PROPOSED BUILDING USE
X
NUMBER OF STORIES BUILDING HEIGHT NUMBER OF UNITS
GENERAL
PROPERTY CONSTRUCTION TYPE: 1 II III IV V VI; P OR U
INFORMATION
3 9c
7
SQUARE FOOTAGE: LIVING ?1
p COMMERCIAL
GARAGE/CARPORT OTHER TOTAL
PL64SEFILL OUTBACKPAGE-APPLICA TIONMUSTBE COMPLETE
\1
?V
V
0
CL)
Office Only
`\ # O co
:._..
T
icO 41i
-?' O
Office Only
IF FAX PERMIT, PLEASE ENTER PROPERTY ADDRESS HERE:
PROJECT DESCRIPTION /
?- ^r ! ea /i LX, S ys S ?f'n'?
J
NATURE
OF WORK
(CHECK
ALL THAT
APPLY)
LIBUILDING
??? MECHANICAL
DROOFING
LANDSCAPING
(TRAFFIC OPERATIONS
'ELECTRIC
GAS
ENGINEERING
UTILITIES
CLEARING & GRUBBING
LUMBING
FIRE
LAND RESOURCES
NEAR WETLANDS
OTHER
TYPE OF WORK 'NEW ADDITION OREMODEL [1]REPAIR % DEMOLITION OTHER
VALUATION: $ C? 5D, 00 (THIS MUST BE FILLED IN, PLEASE PRINT CLEARLY)
BOARD REVIEW REQUIRED: i,-9 DRC DATE: CASE (circle one): FL OR FLS #
=CDB DATE: APPROVED IDDENIED
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 I 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_NOX
PAYMENT METHOD: 0 CASH .]CHECK CREDIT CARD - If paying by credit card include authorization form.
Signature of License Holder ORAutho&ed Personnel
Date
Please Print Name Here / Tide in Firm or Homeowner