Driveway Permit -Indian Rocks Beach

Driveway Permit

Flood Zone

Project Address

Street Address Address Line 2 City State ZIP Code

Parcel ID #

Legal: Lot

Block

Subdivision

Owner's Name

First Last

Owner's Phone

Owner's Address

Street Address Address Line 2 City State ZIP Code

Owner's Email

Fee Simple Titleholder’s Name

First Last

if other than owner

Fee Simple Titleholder’s Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

if other than owner

Contractor's Company Name

Contractor's Address

Street Address Address Line 2 City State ZIP Code

Contractor's Fax #

Contractor's Phone

Contractor's Email

State Certification/Registration # or Certificate of Competency #

PCCLB #

Contact Person

First Last

Contact Person's Phone

Present Occupancy /Use

Structure Type

Commercial

Residential 1 or 2 units

Residential 3 or more units

Contract Valuation $

Description of Work

Will be reviewed for impervious areas and drainage.

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