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Ilia NXI. I-A .1 ,'[ !i,is i 10 7124 3-10n7
PERMIT NUMBER 89-2535
PROPERTY CHANGE
A F F I D A V I T
Before me, the undersigned uthorit personally appeared the OWNER of the
described property:
roperty Owner's Name)
who, being by me the first duly s, n, on oath deposes and says:
1. That he is the fee simple OWNER of the following decribed property:
706 N. LAKE AVE LA HACIENDA
Number Street Subdivision
Lot 3&4 Block (y) Type of Structure SFR
Property Control Number 12 43 46 09 11 004 0030
2. That he intends to : DEMOLISH ;
or is MOVING the building(s) , leaving O building(s) on this
(Number)
property; or will MOVE O building(s) ONTO this property.
(Number)
i
4v�/3. That he has appointed Oc...yEx, �� °t-- "'� to act
(Name)
as AGENT on his behalf to accomplish the above.
SIGNED:
R OF RECORD
BUILDING OFFICIAL: SWO & SUBSCRIBED BEFORE ME THIS
DAY OF
19
dGNATURE & DAT
cc: City Clerk
P.B. County NOTARY PUBLIC
Utility Billing STATE OF FLORIDA AT LARGE
Notary Public, State of Horida
Disk:Forms/App Mr Commission Expires Feb. 4, 1"2
B:PropChg.Aff po.ad iMu my fila;lq,unacuhy ,.`
REQUEST FO Ri@@N@R CHANGE OF ADDRESS
;�AAI�r oqx.� S�,
(NAME) (ADDRESS) f
�52- 3�
(PHONE N0, )
LOCATION :
LEGAL DESCRIPTION:
(SUB—DIVISION) (BLOCK NUMBER)
3 7 3�
(LOT NUMBER)
*4ety:
(SIGNA URE & DATE
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THE FOLLOWING ADDRESS HAS BEEN ASSIGNED TO THE ABOVE:
(NUMBER) (STREET NAME)
' APPROVED BY:
i
Copies To:
i
Utility Billing t
; DELRAY BEACH FIRE DEPARTMENT
Arlene Eubank, Public Utilities j p
Donna Quinlan, Building Dept. (2)
City Clerk DATE
Steve Ford, Engineering
Police Dept. Administrative Div.