BCP2011-07020u
`' Planning & Development Department
100 S. Myrtle Avenue, Suite 210
t~~, ~'~' Clearwater, FL 33756
`' ~ I PERMIT APPLICATION 567 Fax: (727) 562-4576
JUN 2 g 201 '~ www.myc%an~vate~com
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' ~'".~~`/~'~''~P"~~ vd SERVJCES DEPT
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PARCEL NUMBER ~ / Z~ / ' ~ / / ~ ~ ~ / y~ / Oo~p
PROJECT PROJECT/JOB NAME ~ >~~~~ O ~ u Y \
LOCATION PROJECT ADDRESS ~d-~ ~ ~~~~~p19t \ ~' ZIP 33~~
BUSINESS NAME II PHONE ~~,~,~(~
LEGAL DESCRIPTION OF PROPERTY ~t Ql Q ~ 1.~~
PROPERTY OWNER NAME ~'~ ``I ~~- ~, 5~~~ `J'~ ~ ',
PROPERTY Q
OWNER ADDRESS l~ ~~~~X~ Y ~ Q
(must have ` ~ ,~ ,,~ ^~Q
phone CITY ~~J~-~ " y STATE `~ ~ ZIP s~ S Q.
number) (~j
PHONE ~~Z`l _ 2~10'~~ ~ ~ S •f~`~- $~~ ~ ~ 1~~~ 1
C~
NAME
ARCHITECT/ ADDRESS
ENGINEER
CITY STATE ZIP
PHONE FAX Office Only
E-mail:
NAME OF COMPANY ~ ~Cl~ K~'~ ~C
CONTRACTOR LIC. HOLDER ~~ An G(/l/v PHONE / Z ~ ~I~
ADDRESS ~ U ~ "' ~ ~ FAX _ _
(please print 1 ~ / G
clearly) CITY Oc v~ STATE ZIP ~~ `~I ~ ~..1 ~ ~
3 ~_ ~ ~....._
~~W 122 ~ , , ~ ~,v.....~~r,F-i~~
STATE LICENSE PCCLB # ~ ~
C ~~
Contractor E-mail: r- -~~
O ~`
Contact for this project a-mail: n, F,,, ~
e.:~:
L1 "~ N
EXISTING BUILDING USE PROPOSED BUILDING USE ' ~ ~ `~ _° Ld.
a,y f':;
GENERAL NUMBER OF STORIES 2- BUILDING HEIGHT NUMBER OF UNITS_~ ', ~ m~~..._....~_,.~
PROPERTY CONSTRUCTION TYPE: I II III IV V VI; P OR U ~ ~ `~~'-"~--~°°`',~'!
INFORMATION
SQUARE FOOTAGE: LIVING ~ ~~ COMMERCIAL
GARAGE/CARPORT ~ OTHER TOTAL Office Only
PLEASEF/LL OUTBACKPAGE-APPL/CAT/ONMUSTBECOMPLETE ~- -- --~------- -
IF FAX PERMIT, PLEASE ENTER PROPERTY ADDRESS HERE:
NATURE ]BUILDING
OF WORK MECHANICAL
(CHECK CROOFING
ALL THAT
APPLY) L:LANDSCAPING
!:..~TRAF lC~E~
r ELECTRIC
:GAS
'ENGINEERING
I~- ~~
~~.~.IUTILITIES
I„..CLEARING & GRUBBING
'~LUMBING
'FIRE
` LAND RESOURCES
a...:NEAR WETLANDS
'~~~OTHER
~~w_=
TYPE (~.t~IORK: ~~R1EW )ADDITION`"REMODEL
VAL~JATION: $ ~~O ~ ' (THIS M
AIR ..1DEMOLITION BOTHER
r ~'
BE FILLED IN, PLEASE PRINT CLEARLY)
BOARD REVI QUIRED: ~ DRC DATE: ASE (circle one): FL OR FLS #
h.C IE: I~.jAPPROVED 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
incompliance 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_NO_
PAYMENT METHOD: ~ CASH CHECK ~ CREDIT CARD - If paying by credit card include authorization form.
Signature of License Ho/der ORAuthorized Personnel
CVI,t ~~~ D'~~ ~~~~
P/ease Print Name Here /Title in Firm or Homeowner
~~29~ i l
Date