007993
PLEASE TYPE OR PRINT FIRST
CENTRAL PERMIT RECEIPT FORM Pinellas County
310 COURT ST. CLEARWATER, FL. 33756 NAME
REF. NO.
OWNER NAME: OWNER ADDRESS: CITY: ARCHITECT / ENG: CONTRACTOR: CONTR. COMPANY: CONTR. ADDRESS: CITY:
CONSTR. ADDRESS:
TEL: STATE TEL: FCILB: PCCLB: TEL: STATE: STATE: FL. ZIP: ZIP: ZIP
CITY: PROJECT NAME/SUBPROJECT NAME:
□ BUILDING □ ELECTRIC □ PLUMBING □ GAS □ MECHANICAL □ SPRINKLER □ HOOD □ CHEMICAL □ REFRIGERATION □ FIRE INSPECTION □ PLAN REVIEW □ THRESHOLD □ VIOL X
TOTAL BUILDING FEE
$ $ $ $ $ $ $ $ $ $ $ $ $ $
SUBDIVISION: PARCEL ID # ZONING:
SETBACKS
SECTION: BY:
TWP: UNITS: C.O.C. NO. MAX. HGT.
RANGE: OF:
SUBDIV.NO:
BLOCK: REQ’D ELEV: OCCUPANCY:
LOT: INT:
FLOOD ZONE:
TYPE OF CONSTRUCTION I II III IV V VI ON CPR# SQ. FT. RADON AREA SQ. FT. X RATE $ SQ. FT. PER SQ. FT.=ELEVATION
INTIAL PLAN REVIEW: CONDITIONED AREA
FRONT
AREA MISC. INFO.
WORK DISCRIPTION:
Zoning Habitat Mgmt. Building Radon Bldg. Misc. Water Tap □ Impact Back Flow Well
$ $ $ $ $ $ $ $
PERMIT NUMBER
Sewer Con □ Septic $ Sewer Tap $ Swr Const Cntrb Share $ Palm Harbor Fire $ Transportation $
□ Paid □ Not Paid
SIGNATURE DATE
I hereby swear (or affirm) that the information provided in applications for the above Indicated permits is true and complete to the best of my knowledge.