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CITY OF SANFORD PERMIT APPLICATION
Application #: V/31
Job Address:32 L '32
Parcel ID:
Description of Work:
Zoning: _
Submittal Date: C q /ja/,D-
Value of Work: $ -�> d " 0
Historic District:
Square Footage:
•...........................'...........•...........•..................Vyv.,J...........................................
Permit Type: 'Building ❑ Electrical ❑ Mechanical ❑ Plumbing PK Fire Sprinkler/Alarm ❑ Pool ❑ Sign 0
Electrical: New Service - # of AMPS Addition/Alteration ❑ Change of Service ❑ Temporary Pole ❑
Mechanical: Residential 0 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 ❑ Commercial ❑
Occupancy Type: Residential Commercial ❑ Industrial ❑ Occupancy Use Group(s):
Construction Type: bID(L # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required)
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Property Owner: a� T
Contractor:!. l a..
Address: 03 Address: bN d I ` q0Z
n2
..2 -- _ E -m 1: Spe1L i'%��"1 Cl t"t ICY �# i 1, F� o6
/Phone: Phone: tate License Number:
onding Company Mortgage Lender:
Address: Address:
Architect/Engineer: Phone:
Address: Fax:
Plan Review Contact Person: Phone: Fax: E-mail:
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 found in the public records of
this county, and th ay be ad itional permits required from other governmental entities such as water management districts, state agencies, or federal agencies.
Acceptance of Y 1 t ^ verific atitiat I will notify the owner of the property of the requirements of Florida Lien Law, FS 713.
'
VU (7- Co .7
of Owne Agent_ , , L k] M11. Signature of Contractor/Agent Date
• a 1 n . l,-, j Print Contractor/Agent's Name
S' a r f No State o lorida Date `�r � " ^ `
tary- J m Signature of Notary -State of Florida Date
-P H�� 299 .�
j � Jy,� tf ThrU � 1 � • Q \ _
Owner/Agent is Personally Kno $1A �• \� Contractor/Agent is _ Personally Known to Me or
Produced ID 1. I (� 5 3Ci •-/ j� l r r `r _Produced ID
APPROVALS: ZONING: UTIL: FD: ENG: BLDG:
Special Conditions:
Rev 02/2007
2 S;OCA•
City of Sanford
Owner/ Builder Affidavit
Construction Contracting
State law requires construction to be done by licensed contractors. You have applied for a permit under an
exemption to that law. The exemption allows you, as the owner of your property, to act as your own
contractor with certain restrictions even though you do not have a license. You must provide direct, onsite
supervision of the construction yourself. You may build or improve a one -family or two-family residence
or a farm outbuilding. You may also build or improve a commercial building, provided your costs do not
exceed $75,000. The building or residence must be for your own use or occupancy. It may not be built or
substantially improved for sale or lease. If you sell or lease a building you have built or substantially
improved yourself within 1 year after the construction is complete, the law will presume that you built or
substantially improved it for sale or lease, which is a violation of this exemption. You may not hire an
unlicensed person to act as your contractor or to supervise people working on your building. It is your
responsibility to make sure that people employed by you have licenses required by state law and by
county or municipal licensing ordinances. You 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 your
building who is not licensed must work under your direct supervision and must be employed by you,
which means that you must deduct F.I.C.A. and withholding tax and provide workers' compensation for
that employee, all as prescribed by law. Your construction must comply with all applicable laws,
ordinances, building codes, and zoning regulations.
I, , do hereby state that I am qualified and capable of performing the
requested construction involved with the permit application filed.
I will assume full responsibility as an Owner/Builder Contractor, and will personally supervise all work
the
Owe r/Builder Si n to ;•��� �\�ory 76
O
Owner is Persor�l Igw{���t,•c lis Produced ID
Signature of Notary—State of Florida Date
My Commission Expires:
h, L w 6 30- 3 '� O--10^ $ Z I— C