HomeMy WebLinkAbout1201 Mellonville Ave 04-234 pole lightsCITY OF SANFORD PERMIT APPLICATION
Permit # : A Date:
Job Address:
Description of Work: Ales/
v -
Historic District: Zoning: Value of Work: $
Permit Type: Building Electrical _V_ Mechanical Plumbing Fire Sprinkler/Alarm Pool
Electrical: New Service — # of AMPS '30 Addition/Alteration Change of Service Temporary Pole Mechanical:
Residential Non -Residential Plumbing/
New Commercial: # of Fixtures Plumbing/
New Residential: # of Water Closets Occupancy
Type: Residential Commercial Construction
Type: # of Stories: Replacement
New (Duct Layout & Energy Calc. Required) er
rh u' T F(
L of
Water & Sewer Lines # of Gas Lines Plumbing
Repair — Residential or Commercial Industrial
Total Square Footage: of
Dwelling Units: Flood Zone: (FEMA form required for other than X) Parcel #: (
Attach Proof of Ownership & Legal Description) Owners
Name & Address: eir' V SQn1 262-,l I Z S/
Phone: /
Contractor
Name & Address: e%+ <7/Q QFLC SC-%7 I IW— Or / ,C e State
License Number: <4 - c kVIN 7 7 O Phone &
Fax: -,(d7"a7S- -72- Z-6 /` 19,A SFIn Eontact Person: C M V 6N'o-4 l L.<- Phone:&/-( Bonding Company:
Address: Mortgage
Lender:
Address: Architect/
Engineer:
Phone: Address: Fax:
Application is
hereby made to obtain a permit to do the work and installations 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 standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must
be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, and AIR CONDITIONERS,
etc. OWNER'S
AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and
zoning. 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 AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT. NOTICE: In
addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of this county,
and there may be additional permits required from other governmental entities such as water managqfnent districts, state agencies, or federal agencies. Acceptance of
permit is verification that I will notify the owner of the property of the requir _enFlien Signature of
Owner/Agent Date Signature of Contractor/Agent Date e/sra
o G74 Print Owner/
Agent's Name r ontractor/Age is ame o a
l Signature of
Notary -State of Florida Date atur gt+No S c GRAVE Date MY COMMISSION
t DD 164280 EXPIRES: November
12, 2006 rFOF Ft
41 Bonded Thru Budget Notary Services Owner/Agent
is _ Personally Known to Me or C ractor/Agent isPe na y Known to Me or ^ Produced ID Produced
ID \ lay Ul", - 6,3-V APPLICATION APPROVED BY:
Bldg: Mt Zoning: Utilities: FD: Initial & ate) (Initial &
Date) (Initial & Date) (Initial & Date) Special Conditions: