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SEP t I
Job Address: 21
Parcel ID:
CITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Application No: C7 oq
Documented Construction Value:_' _$,
26 l < 120 storic District: Yes,$ No
ResidentiatE Commercial
Type of; Work: New Addition Alteration, Repair De7 Change of Use Move El_
1 , r
Description of Work:
Plan Review Contact Person: Title:
Phone: Fax: Email:
19 Pr perty Owner Information
Nam GcJ Se-t/r' Phone:(
Street: 2 :zzl Resident of property?;.:....
City, State Zip:
Contractor Information
Name- Phone:
Street: Fax:
City, State Zip:
Name:
Street:
City, St, Zip: _
Bonding Company:
Address:
State License No.:
Architect/Engineer Information
Phone:
Fax:
E-mail:
Mortgage Lender:
Address:
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.
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.
FBC 105.3 Shall be inscribed with the date of application and the code in effect as of that date: 5t' Edition (2014) Florida Building Code
Revised: June 30, 2015 Permit Application
I
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 Ipayment of a plan review fee at the time of permit submittal. A copy of the executed contract is required
in order to calculate a plan review charge and will be considered the estimated construction value of the job at the time of submittal.
The actual construction value will be,frgured based on the current ICC Valuation Table in effect at the time the permit is issued, in
accordance with local ordinance. .Should calculated charges figured off the executed contract exceed the actual construction value,
credit will be applied to yourrpermit fees when the permit is issued.
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.
Signature of On er/ gent Da Signature of Contractor/Agent Date
Print er/Agent's Name Print Contractor/Agent's Name
tgnature of Notary -State o Florida ' 'j Signature of Notary -State of Florida Date
DEBBIE BIANTON 1
NAY COMMISSION k FF 178646
EXPIRES: February 2.5, 2019
l Bonded Th- Notary,Publlc Underwriters
Owner/Agent is Personally Known to Me or Contractor/Agent is Personally Known to Me or
Produced ID Type of ID Produced ID Type of ID
BELOW IS FOR OFFICE USE ONLY
Permits Required: Building Electrical Mechanical Plumbing Gas Roof
Construction Type: Occupancy Use: Flood Zone:
Total Sq Ft of Bldg: Min. Occupancy Load: # of Stories:
New Construction: Electric # of Amps
Fire Sprinkler Permit: Yes No
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
Plumbing - # of Fixtures_
of Heads Fire Alarm Permit: Yes No
UTILITIES:
FIRE:
WASTE WATER:
BUILDING:
Revised: June 30, 2015 Permit Application
OWNER BUILDER STATEMENT/AFFIDAVIT
Altamonte Springs, Casselberry, Lake Mary, Longwood, Oviedo, Sanford,
Seminole County, Winter Springs
Florida Statutes are quoted here in part for your information to indicate the authority for exemptions for
homeowners from qualifying as contractors and to express any applicablerestrictions and responsibilities. OWNERS
MUST PERSONALLY APPEAR AT THE BUILDING DIVISION TO SIGN. THIS DOCUMENT BY
SIGNING THIS STATEMENT, I ATTEST THAT: (Initial to the left of each statement) I
understand that state law requires construction to be done by a licensed contractor :and have applied` for an
owner -builder permit under an exemption from the law. The exemption specifies that l; as the owner of the
property listed, may act as my own contractor with certain restrictions even though I do not have a license.
I
understand that building permits are not required to, be signed bya property ownerunless he or she is responsible for the
construction and is not hiring a licensed contractor to assume responsibility. I understand that,
as an owner -builder, I am the responsible party of record on a. permit. I understand that I may protect myself
from potential financial risk by hiring a licensed contractor and having the permit filed in his or
her name instead of my own name. I also understand that a contractor is required by law to be licensed in Florida
and to list his or her license numbers on all permit and contracts. I understand that
I may build or improve a one -family or two-family residence or a farm outbuilding. I may, also build
or improve a commercial building if the costs do not exceed $75,900. The building or residence must be
for my` own use or occupancy. It may not be built or substantially improved for sale or lease; -If a
building or residence that I have built or substantially improved myself is sold or leased within in 1 `year
after the construction' is complete, the' law wilif.prestime that I built or substantially improved it for sale or
lease, which violates this exemption. I understand that,
as the owner -builder, I must provide direct, onsite, supervision of the construction. I understand that
I may not hire an unlicensed individual person to act as my contractor or to supervise persons working on
my building or residence. It is my responsibility to ensure that the persons whom I employ have the
licenses'required by law and by city ordinance. 1 understand that
it is a frequent practice of unlicensed persons to have the property owner obtain an owner -builder permit
that erroneously implies that the property owner is providing his or her own labor and materials. 1,
as an owner -builder, may be held liable and subjected to serious financial risk for any injuries sustained by
an unlicensed person or his or her employees while working on my property. My homeowner's insurance
may not provide coverage for those injuries. I am willfully acting as an owner - builder and am
aware of the limits, of my insurance coverage for injuries to workers on my property. I' understand that
I may not delegate the responsibility for supervising work to a licensed contractor who is not licensed to
perform the work being done. Any person working on my building who Is not licensed must work under
my direct supervision and must be employed by me, which means that,I must comply with laws
requiring the withholding of federal income tax and social security contributions under the Federal
Insurance Contributions Act (FICA) and must provide workers' compensation for the employee.
I understand that my failure to follow these laws may subject me to serious financial risk. Rev. 9.
14.
2009
t
I agree that, as the party :legally and financially responsible for this proposed construction activity, I will
abide by all applicable laws and requirements that govern owner -builders as well as employers, I also
understand that the construction must comply with all applicable laws, ordinances, building codes, and
zoning regulations.
I am of aware of construction practices and I have access to the Florida Building Codes.
I understand that I may obtain more information regarding my obligations as an employer from the Internal
Revenue Service, the United States Small Business Administration, the Florida Department of Financial
Services, and the Florida Department of Revenue. I also understand that I may contact the Florida
Construction Industry Licensing Board at 1-850-487-1395 or at www.myflorida.com/dbpr/pro/cilb/ for
more information about licensed contractors.
I am aware of, and consent to, an owner -builder building permit applied for in my name and understand
that I am the party legally and financially responsible for the proposed construction activity at the address
listed below.
I agree to notify the building department immediately of any additions, deletions, or changes to any of the
information that I have provided on this disclosure or in the permit application package.
Licensed contractors are;: regulated by laws designed to protect the public. If you contract with a person
who does not have a license, the Construction Industry Licensing Board, the Department of Business and
Professional Regulation and the building department may be unable to assist you with any financial loss
that you sustain as a result of a complaint. Your only remedy against an unlicensed contractor may be in
civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an
individual or firm is injured while working on your property, you may be held liable for damages. if you
obtain an owner -builder permit and wish to hire a licensed contractor, you will be responsible for verifying
whether the contractor is property licensed and the status of the contractor's workers' compensation
coverage.
r
Property Address:
I, %! , do hereby, state that I am qualified
and capable of per r ing th r ueste onstruction involved with the permit application filed and agree to the
condition ecifie above.
S nature of 0,6ner/B&16er 17 Date
Form of IdenWation
Must be Photo ID)
A violation of this exemption•is a misdemeanor of the first degree punishable by a term of imprisonment
not exceeding 1 year and a $1,000.00 fine in addition to any civil penalties. In addition, the local
permitting jurisdiction shall withhold final approval, revoke the permit, or pursue any action or remedy
for unlicensed activity against the owner and any person performing work that requires licensure under
the permit issued.
Rev. 9.14.2009
Answer all the questions on this form and submit all required attachments. Incomplete applicationswill not be reviewed
If you have questions about application requirements contact the Historic Preservation Officer at 407.
688.6146 to ensure' your` application is complete. General
Information Downtown
Commercial Historic District[] Residential Historic District. Is this a retroactive request? Yes No Is
this application filed in response to a Notice of Violation from the Code'Enforcement Department?. YesO No0 Proposed
improvements will affect the following elevations: North South q East West Property
Address: _ l ' Z Z l ` /2U ,e Property
Owner Information Print
Name: Mailing
Address: %D S j G GI j 1 U Phone:
YG!' lvZEmail: Signature: \ % 2 V
Applicant/
Agent Information Print
Name: Mailing
Address:. Phone:
Email: Signature: BY
SIGNING BELOW YOU ACKNOWLEDGE THAT A BUILDING PERMIT MAY BE REQUIRED FOR THE SCOPE
OF WORK LISTED BELOW. YOU MUST CONTACT THE BUILDING DEPARTMENT TO DETERMINE
IF A BUILDINGPERMITIS REQUIRED. FAILURE TO OBTAIN A BUILDING PERMIT WILL RESULT IN
A STOP 'WORK ORDER, DOUBLE PERMIT FEES, AND POTENTIAL FINES. BY SIGNING BELOW, YOU
ALSO -ACKNOWLEDGE THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND
ACCJRATE'TO THE BE F YOUR KNOWLEDGE. Signature. Date:
Would you
like to ee/eivie emai /egarding YHtstor, isPreservation and Community Planning within your community? Description of
proposed work Completely describe
the entire scope of work; including changes in material and color, and methods that will be used to accomplish the
proposed work. For large projects an itemized list is equired. Use the reverse side if necessary. ll HISTORIC
PRESERVATION
BOARD • 300 S. Park Avenue • Sanford, Florida 32771 •407.688.5145 • www.sanfordf1.gov1HP
LEGAL DESCRIPTION: LOT 6, BLOCK 14,
77ER 5, FLORIDA LAND COLONIZA77ON
COMPANY LIMITED E.R. TRAFFORD'S MAP
OF TOWN OF SANFORD, ACCORDING TO
7HE PLAT 7HEREOF, AS RECORDED IN
PLAT BOOK 1, PAGE 60, OF THE PUBLIC
RECORDS OF SEMINOLE COUNTY,
FLORIDA.
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Fes.'-•e.a'v..F.ue.'r^:'i .-:
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217 WEST 12TH STREET
SANFORD, FL.
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5)rucinli:ing in R,.tsideulK"1 S uti Yiug"
LB.Na, 7J71
1061 S. Sun Dr. Ste.- hl 113
Lake Mary, 1 L 32746
Office 407-330-9717or407-330-971.6
Fax 407-330-9775
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KZR BRETT
CERT7fRD TO.
MARK WYSONG
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Cfwl 2)
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riot. of way or mfif.uan. of recrrd ehlN may
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seal ar the a/phd MLeed sad of a Radde lkalsed
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and that It m CRTs, fbR hktum tecml w standards set
fMA by the Bpa_Ld( oL d Land SLr»Iors avd Mappers
k Chq* 0.%7p AdmhOtratlw Cod4 pumuan4YN .
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