HomeMy WebLinkAbout215 W 18 StCITY OF SANFORDAddBUILDING & FIRE PREVENTION
PERMIT APPLICATION
Application No: Documented Construction Value: $ c,2490• U
Job Address: Ll kl- 18t 5- 06rd 3a?? Historic District: Yes No
Parcel ID:(! -/GJ 3b-5LYo--0o0o- Q/09 Zoning:
Description of Work: -D /l L%P17 • ,/G/(1Y1
Plan Review Contact Person: Title:
Phone: Fax: E-mail:
Property Owner Information
Name` rek s c Jc
l.
m L,l oer Phone: Street:
PO ,6OX , ,38 (-en rd o . 0 Z-71-0 Resident of property?: City,
State Zip: Contractor
Information Name
E I" T l AjmAlna Phone: (- 7 `JT— 090q Street:
G Fax: BL'D' 7 Y — Q0(-/8/ City,
State Zip: -. 1 . F 32, State License No.: SOSIp Architect/
Engineer Information Name:
Phone: Street:
City,
St, Zip: Bonding
Company: Address:
Building
Permit 01, Fax:
E-
mail: Mortgage
Lender: Address:
PERMIT
INFORMATION Square
Footage: 1, Q-79 Construction Type: No. of Stories: No.
of Dwelling Units: Flood Zone: Electrical
New
Service — No. of AMPS: Mechanical (
Duct layout required for new systems) Plumbing [
91'_ New
Construction - No. of Fixtures: Fire
Sprinkler/Alarm 0 No. of heads:
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. A NOTICE
OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE
FIRST INSPECTION. 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 requirements of Florida
Lien Law, FS 713.
The City of Sanford requires payment of a plan review fee. A copy of the executed contract is required in order
to calculate a plan review charge. If the executed contract is not submitted, we reserve the right to calculate the
plan review fee based on past permit activity levels. Should calculated charges exceed the documented
construction value when the executed contract is submitted, credit will be applied to your permit fees when the
permit is released.
Signature of Owner/Agent Date
Owner/Agent's Name
Signature of Notary -State of Florida Date
Owner/Agent is Personally Known to Me or
Produced ID Type of ID
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
UTILITIES:
FIRE:
Signature of ontractor/Agent Date
6ZI W . Evers &l-VlI,
Print Contra for/Agent's Name
Signature of Notary -State of Florida Dale
DONNA ANZALONE
MY COMMISSION # DD 885059
EXPIRES: April 29, 2013
f of qya ` 'bonded Thru Notary Public Underwriters
Contractor/Agent is Personally Known to Me or
Produced ID Type of ID
WASTE WATER:
BUILDING:
Rev 11.08
LIMITED POWER OF ATTORNEY
lie . 3D,I Q?b! I
Date
I hereby authorize -/5 jG/ )6r
of Fj 0 ua //
to sig4L; ier name on my behalf in order to apply fora permit
for the work to be performed at:
LotSubdivision L5±
a lr&/I yOlnIib- (?FC O S0S(0C Type
or Print Name of tompany and License # of Contractor Signature
of Licensed Contractor If
applicable only! Type
or Print Name of Owner Signature
of Owner STATE
OF FLORIDA VOLUSIA_
COUNTY The
foregoing instrument was acknowledged before me this 3-0 A-,.- day of -0Tkr-4- 20 \_,
by &axf Vj , ss kx s (name of person acknowledging). tie.,
DONNAANZALONE MY
COMMISSION # DI M5051 Londed
hEXPIRES: 13
ru Notary
Public Underwriters Signature of
Notary Public Otate of Florida) O tit-
Print, Type
or Stamp Commissioned Name) Personally known *
OR produced identification Type of
identification produced:
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B'DSTEms 2URLITYray, ING7ONIN—
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JCOORo® CERTIFICATE OF LIABILITY INSURANCE OPID ,i
DATE(MM/DD/YYYY)
06/30/11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAII'VED, subject to
the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
NAME: Aileen Vega
A/CEXc: 386-736-6444 (wc,No): 386-736-677 SihleInsuranceGroup /DEL 5 E-
M,No _
IL
ADDRESS:
avega@sihle.com 1300SWOODLANDBLVDDELAND
FL 32720 Phone:
386-736-6444 Fax:386-736-6772 CUSTOMERID#:
FIRST44 INSURER(
S) AFFORDING COVERAGE NAIC# INSURED
First
uality Plumbing & Irrigation,
Inc. Gary
Wayne Evers License
number: CFC050566 746
N Volusia Ave INSURERA:
State Auto Insurance Company 000856 INSURER
B: BridgeField Casualty Ins. Co. INSURER
C : INSURERD:
Orange
City FL 32763 INSURERE: INSURER
F : COVERAGES
CERTIFICATE NUMBER: REVISION NUMBER: THIS
IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE
MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS
AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR
TYPE OF INSURANCE INSR ut"
POUCY
NUMBER MMIDD/YYYY) MCVDD/YYYY) LIMITS GENERAL
LIABILITY EACH
OCCURRENCE 1000000 A
MMERCIALGENERAL LIABILITY CLAIMS-MADE
OCCUR lxl PBP229860001/
01/li PRPREMSE(EaoNTEUnce) c 100000MED EXP (
Any one person) s 5000 PERSONAL& ADV
INJURY 1000000 contractual DLNKTADDILINSRDCG2033IGENERAL
AGGREGATE s 2000000 GEN'LAGGREGATELIMIT
APPLIES PER: PRODUCTS-COMP/OPAGG 52000000 POLICY X JET
I LOC A AUTOMOBILE X
LIABILITY
ANY
AUTO
BAP2139078
01/01/11 01/01/12 COMBINED SINGLE LIMIT
Ea accident) lOOOOOO
BODILY INJURY (Per
person) ALL OWNED AUTOS
BODILY INJURY (Per
accident) S X SCHEDULED AUTOS
HIRED
AUTOS PROPERTY
DAMAGE Per
accident) S
X NON-
OWNEDAUTOS
A X UMBRELLA
LIAB X OCCUR PBP2298600 01/01/11 01/01/12 EACH OCCURRENCE 1000000 EXCESS UAB CLAIMS -
MADE AGGREGATE S 1000000 DEDUCTIBLE RETENTION S
0
S B WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y / N ANY PROPRIETORIPARTNER/EXECUTIV
OFFICER/MEMBER EXCLUDED?
NIA 083033735 HLNKT WAIVER
OF
SUBROGATI 03/13/11
03/13/12 X A - X TORY LIMITS IERE.L. EACH
ACCIDENT 1000000 E.L. DISEASE -
EA EMPLOYEE S 1000000 Mandatory In NH) If yes, descnbe
under E.L. DISEASE -
POLICY LIMIT S 1000000 DESCRIPTION OF OPERATIONSbelowAEquipmentFloater
PBP2298600 01/01/11 0l/01/12 leased 40,000 or rented DESCRIPTION
OF OPERATIONS /
LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Plumbing Contractor- residential
and commercial GEKIIFIGATE HOLDER CANCELLATION
SHOULD ANY OF
THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY SA THE
EXPIRATION DATE THEREOF, NOTICE WILL -BE DELIVERED IN CITY OF SANFORD
ACCORDANCE WITH THE POLICY PROVISIONS. 407-330-5677
300 N. PARK
AVE AUTHORIZED REPRESENTATIVE P.
O.BOX
1788 SANFORD FL 32772 _
RPORATION. All rights
reserved. ACORD 25 (2009109)
The ACORD name and logo are registered marks of ACORD
05/14/2010 01:50 3867740048 FIRST QUALITY PLUMBG
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