HomeMy WebLinkAbout220 W 19 St 04-670 Water Heater replacementPermit # : V — 06
Job Address: !/L
Description of Work:
Historic District: Zoning:
CUY OF SA_NFORD PERMIT APPLICATION
Date:
Value of Work: $
Permit Type: Building Electrical Mechanical Plumbing Fire Sprinkler/Alarm Pool
Electrical: New Service - # of AMPS Addition/Alteration Change of Sen!ice Temporary Pole
Mechanical: Residential Non -Residential Replacement New (Duct Layout & Energy Calc. Required)
Plumbing/ New Commercial: # of Fixtures # of Water & Sewer Lines # of Gas Lines
Plumbing/New Residential: # of Water Closets Plumbing Repair eside or Commercial
Occupancy Type: Residential Commercial Industrial Total Square Footage:
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required for other than R)
Parcel #: J%- I 0'56 -CUOO' (Dqxk (Attach Proof of Ownership &&Legal Descn tion)
Owners Name &Address: 1y, (( 1 _(% LA W - ( S f - J/ l UQ i Z77 Contractor
Name & Address: t01t Phone: `
tt/ ( - "7G 5 J
State
License Number: -iC- t J ( t W j 1 Phone &
Fax: (J.%1t- p7- Contact Person: f 5 I(, phone:75 q%S'l 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. 3z175
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 restrictioWeprohat may be found in the public records of this
county, and there maybe additional permits required from other governmental entitieistricts, state agencies, or federal agencies. Acceptance
of permit is verification that I will notify the owner of the property of the requ, FS 713. Signature
of Owner/Agent Date Signature of Contractor/gent Date Print
Owner/Agent's Name Print Contractor/Agent's Name Signature
of Notary -State of Florida Date Signature of Nota ate of Florida Date Owner/
Agent is - Produced
ID Personally
Known to Me or APPLICATION
APPROVED BY: Bldg: Initial &
Date) Special
Conditions: Martha
Jackson Hartman t PLetCy'y;, 244694 Contractor/
Agent is _ Personally_4gi N"rl; Gtommission #DD NO
dlD =+' =
plres:Octt Bonded " Co., Inc. AtlanticBondtngZoning:
Utilities: FD: Initial &
Date) (Initial & Date) (Initial & Date)
POWER OF ATTORNEY
Date: Z 2`"
I, Da)A) K(uT-K) do hereby authorize /-&
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to pull the ?LVA4 31 rjpermit for — j l 54A) F0 A-Ibtype
of pernut address Signature
Martha
Jackson Hartman Commission #
DD244694 fires:
Oct 101 2007 a`;
EXp No
ru
4
oe Atlanta Bondin¢ CO., Inc. FPerso
nally known t me or drivers license # State
of Florida, County of \( Q -k C- on day of 1
R fM , 2003. - l
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