HomeMy WebLinkAbout101 Club Rd (4)s
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_ CITY OF SANFORD PERMIT APPLICATION
Permit # : 0� + �� Date: ZS^QS
Job Address: J0/ Ctud
Description of Work: 3erillee e i9iRScor. j;)9�ilA }
Historic District: — — Zoning: Value of Work: S g
Permit Type: Building Electrical _Mechanical Plumbing Fire Sprinkler/Alarm Pool
Electrical: New Service – # of AMPS *UA Addition/Alteration Change of Service –r– 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 – Residential or Commercial
Occupancy Type: Residential ✓ Commercial Industrial Total Square Footage:
Construction Type: No (K # of Stories: _/_ # of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel #: (Attach Proof of Ownership & Legal Description)
Owners Name & Address:
Phone:
Contractor Name & Adddress:�i11/� di` �LeCT C� .NC
5 Aglw State License Number: r= r, 13D0/QY-3
Phone & Fax: L6,— L
Z' j s%2— Contact Person: 1_ Y yy slThiifww Phone: 401'330
j7o�_
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 Ei
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 requireme of Florida Lien Law,
Siof actor/A et Date '
f' 107 Z
Y L o . Sone
PConrc orl7 dent's Name
Signature bENb%-Sta�.6N AA. DE GRAVE Date
%ApMY COMMISSION # DD 164280
PIRES: November 12, 2006
;. _ oti`Op nded Thru Bud et NotarServ'c a
Owner/Agent is _ Personally Known to Me or Contractor/Agent is Personalpy, Kno n td wie or
Produced ID _Produced ID
APPLICATION APPROVED BY: Bldg: Zoning: Utilities: FD:
(Init &Date) (Initial & Date) (Initial & Date) (Initial & Date)
Special Conditions:
E
Signature of Owner/Agent
Print Owner/Agent's Name
Signature of Notary -State of Florida
Date
.Date