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�g5 F_k <br />INDIAN RIFER COUNTY/CITY OF VERO BEACH <br />:* BUILDING DIVISION <br />.ctO. 1801 27th Street, Vero Beach, FL 32960 772- 226-1260 <br />Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation <br />has commenced prior to the issuance of a permit, and that all work will be performed to meet the standards of all laws regulating <br />construction, insurance, and worker's compensation. I understand that sub -contractor affidavits must be obtained for electrical, <br />plumbing, air-conditioning, roofing, insulation, irrigation systems, wells, or any other work that is allowed to be included in this <br />permit. <br />Properties on which earth spills or other debris fails shall be cleaned immediately. All streets, sidewalks, and curbs damaged <br />due to this construction shall be repaired to the satisfaction of the engineering department prior to the issuance of certificate of <br />completion. <br />Owner's Affidavit: I certify that all the foregoing information is accurate and that all work will be done in compliance with all <br />applicable laws regulating construction and zoning. <br />And <br />Signa ure a Wgent <br />Date: 2 <br />Notary as to Owner or Agent: <br />STATE TF FLORIDA, COUNTY OF <br />%4Ic O -A V-P—V <br />Sworn o apd subscribed before me this— -7A day of <br />20 Z l <br />by G rc1 �5 . � Z ra y 1r fG 4 <br />who islE ersonally known or 0 produced identification <br />Type of ID produced /V1 <br />Printed Name ofNotary ,.� L_(t <br />Signature of Notary ( tG-!C_ <br />Notary Seal oP+' S LUANNECL4RK <br />Commissbn a> GO 244341 <br />-� Expires November 6, 2022 <br />° WWW Do Ttq fake I uma 8G6 M7019 <br />This Area For Building Use Only: <br />Building Square Footage: Construction Type: <br /># of Floors: Occupancy Type: <br />Total Square Footage_x ICC Multiplier = <br />Or <br />Contract Value <br />Contractor Signature <br />Date: <br />Notary as to Contractor: <br />STATE OF FLORIDA, COUNTY OF <br />Sworn to and subscribed before me this day of <br />20 <br />by <br />who is 0 personally known or 0 produced identification <br />Type of ID produced <br />Printed Name of Notary <br />Signature of Notary_ <br />Notary Seal <br />ADD REF #: <br />PROJECT #: <br />Page 3 of 9 <br />