HomeMy WebLinkAbout801 W 20 St 04-127 re-pipeCITY OF SANFORD PERMIT'APPLICATIO
Permit # :
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Date:
Job Address: (( 0 S;+rC c-T
Description of Work: P,e , p Q .
Historic District: Zoning: Value of Work: $ o i,c 00
Permit Type: Building Electrical Mechanical Plumbing _Fire Sprinkler/Alarm Pool
Electrical: New Service — # of AMPS Addition/Alteration Change of Service Temporary Pole
Mechanical: Residential Non -Residential Replacement New (Duct Layout & Energy Cale. Required)
Plumbing/ New Commercial: # of Fixtures _ # of Water & Sewer Lines # of Gas Lines
Q
Plumbing/New Residential: # of Water Closets 1 Plumbing Repair — Residential or Commercial % 1
Occupancy Type: Residential f/ Commercial Industrial Total Square Footage:
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel #: (Attach Proof of Ownership & Legal Description)
Owners Name & Address: fr\lit / G Uf. e 41"
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Phone: ZS6
Contractor Name & Address: LA D..J Unt i,, (,/1C ,
Fr' ^
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State License Number: C /— C S7 ()oZ 3
Phone & Fax:36" -7 i — 7a Contact Person: _Jecc C Phone:
Bonding Company:
Address:
Mortgage Lender: _
Address:
Architect/Engineer: Phone:
Address: Fax:
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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 management districts, state agencies, or federal agencies.
Acceptance of permit is verification that I will notify the owner of the property of the requirem is of Florida Lien aw FS 713.
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Signature of Owner/Agent Date Signature of Contractor/Ag nt Date ;fog 05'
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Print Owner/Agent's NamePrint Co O
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re oSignatureofNotary -State of Florida Date Signatuf Notary -State of Poricla Date a c CD
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Owner/Agent is _Personally Known to Me or Contractor/Agent is Personally K own to Me or e """..
Produced ID Produced ID n6(06S-06n t.Ao w :I
APPLICATION APPROVED BY: Bldg:
Initial & Date)
Special Conditions:
Zoning:
Initial & Date)
Utilities: FD:
Initial & Date) (Initial & Date)
10/15/03 10:34 FAX 3867366772 Mindi Sitzer Z 001 ---
C:P ID
DATE (MWDDNYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE LATOW-1 1 10 15 03
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ANC$ GROUP, INC- HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
SIFiLL IN3UR
P . O . SOX 1AN 9$
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
ALTAMONTE SPRINGS FL 32716 NAIC#
Phonet407-869-0962 Fax:407-774-0936 INSURERS AFFORDING COVERAGE
INSURED INSURER A: The Travelers Insurance Co. 2565$
INSURER B. Am m Preferred Insurance Co,
Latow' s Plumbing Inc .
INSURER C:
OrangeuCitygFLA32763 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANYREQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED ORMAYPERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE M UR DATE M D
OENERgLLIABtLITY
A
G
COMMERGIALGENERALLIABILiTY 6603030A299 07/01/03 07/01/04
CLAIMS MADE OCCUR
LIMITS
EACH OCCURRENCE $lOOOOOO
PREMISES Eaoccurence $ 100000.
MED EXP (Any one person) $100 0 0 .
PERSONAL & ADV INJURY $ 1000000
GENERAL AGGREGATE 2000000
GEN'LAGGREGATELIMITAPPLIESPER:
PRODUCTS -COMPIOPAGG 2000000
POLICY JJECGT Loc
11
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Es accident)
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
Per person)
S
SCHEDULED AUTOS
HIREDAUTOS BODILY INJURY
Per accident)
NON -OWNED AUTOS
PROPERTY DAMAGE
Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
OTHER THAN
EA ACC
AUTO ONLY: AGG
ANY AUTO
EXCESMMBRELLA LIABILITY
EACH OCCURRENCE S
AGGREGATE S
OCCUR CLAIMS MADE
8
DEDUCTIBLE
RETENTION $
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERtMEMBER EXCLUDED?
If yes, describe under
SPECIAL. PROVISIONS below
WCV7034848 07/01/03 07/01/04
B TORY LIMITS ER
E.L. EACH ACCIDENT 100000
E.L. DISEASE - EA EMPLOYEd S 100000
E.L. DISEASE - POLICY LIMIT 5 00 0 0 0
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
710N
CERTIFICATE HOLULK
CITY OF SANFORD
407-330-5677
P.O. BOB 1788
SANFORD FL 32772
ACORD 25 (2001/08)
CANCELLA
CITYSNF 3HUULV ..r.vr me nov. w-.-----. ... ___----
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 O DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR