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Permit #
Job Address: - e c JY
Description of Work:
1 t , r RECEIVED
CITY OF SANFORD PERMIT APPLICATION 10 oOC
Date: _ — `
U
Ilistoric District: Zoning: Value of Work: S Z r7
r
Permit Type: Building Electrical Mechanical Plumbing Fire Sprinkler/Alarm t/< Pool
Electrical: New Service — # of AMPS Addition/Alteration Change of Service Temporary Hole
Mechanical: Residential Non -Residential Replacement New (Duct Layout & Energy Cale. 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 —A Industrial Total Square Footage:
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel #•
Owners Name & Address:
Contractor Name & Address: rill
Attach Proof of Ownership & Legal Description)
ear I ay% 60' —T L / py State License Nud(ber:
Phone & Fax: 62' Z 3 S %/od Contact Person: nn /h k Phone: Ah 7 2—
Bonding Company:
Address:
Mortgage Lender:
Address:
Architect/Engineer: Phone:
Address: Fax: s
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. 1 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 1 will notify the owner of the property of the quirements o lorida Lien Law, FS 713,
Signature of Owner/Agent
Print Owner/Agent's Name
Signature of Notary -State of Florida
Date Sigr/tam off ontract /Agent Date
Print Con ctor/Agent's N e
asattttttw
C
Uate Signature of Notary'9tat6vfF1orida are
Owner/Ague is _ Personally Known to Me or Contractor/Agent is
Produced ID ` Produced ID
APPLICATION APPKUVED BY: Bldg: Zoning: Utilities:
Initial & ate) (Initial &Date)
Special Conditions:
Z3 e C?
C&MW0002"q
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Known to Mor .""•••'
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Tyco
Fire & Security
SimplexGrinnell
MAY l 5, 2006
3701 North John Young Parkway
Suite 1 10
Orlando, FL 32804
407) 235-1100 Phone
407) 235-1150 Fax
POWER OF ATTORNEY
I HEREBY AUTHORIZE JOSEPH J. NEMCEK & RYAN FUNK OF
SIMPLEX GRINNELL TO SIGN FOR, APPLY FOR AND PICK-UP FIRE
SUPPRESSION PERMITS IN THE STATE OF FLORIDA
J
V
GEORGE ILLER
BEFORE ME APPEARED GEORGE E MILLER TO ME WELL KNOWN
TO ME TO BE THE PERSON DESCRIBED 1N AND WHO EXECUTED
THAT GEORGE E MILLER EXECUTED SAID INSTRUMENT FOR
THE PURPOSES "THEREIN EXPRESSED.
WITNESS MY HAND AND OFFICIAL SEAL, THIS 16 DAY OF MAY
2005.
NOTARY PUBLIC STATE OF FLORMA
PAMELA A . MCELROY
Notary Public, SMa °27i f ida
My Comm. exp. Comm. No. DD 411691
E
STATE OF FLORIDA "M
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF STATE FIRE MARSHAL
TALLAHASSEE, FLORIDA
CERTIFICATE OF COMPETENCY
THIS CERTIFIES THAT: GEORGE E MILLER
10255 FORTUNE PARKWAY BUILDING 500 SUITE 120
JACKSONVILLE, FL 32256-
BUSINESS ORGANIZATION: SIMPLEX GRINNELL LP
CONTRACTOR 111S LIMITED TO THE EXECUTION OF CONTRACTS REQUIRING THE ABILITY TO LAYOUT, FABRICATE, INSTALL, INSPECT,
ALTER, OR SERVICE WATER SPRINKLER SYSTEMS, WATER SPRAY SYSTEMS, FOAM -WATER SPRINKLER SYSTEMS, FOAM -WATER
SPRAY SYSTEMS, STANDPIPES, COMBINATION STANDPIPES AND SPRINKLER RISERS, ALL PIPING THAT IS AN INTEGRAL PART OF THE
SYSTEM BEGINNING AT THE POINT OF SERVICE, SPRINKLER TANK HEATERS, AIR LINES, THERMAL SYSTEMS USED IN CONNECTION
WITH SPRINKLERS, AND TANKS AND PUMPS CONNECTED THERETO, EXCLUDING PRE-ENGINEERED SYSTEMS.
01 2006 1 07 1 16 1 Duval
Issue Date iTypelclassl County
60476500012001
LicensdPertnit Number
Chief Financial Officer
7626340001 1 150.00 10613012008
Application # I Taxes & Fees I Expirc Date
CITY OF SAOORjb FIRE DEPARTMENT
FEES FOR SERVICES
PHONE # 407-302-2516 - FAX # 407-302-2526
DATE: 43d P;
7,4e—
ADDRESS:
T #: 0
BUSINESS NAME / PROJECT: A e-
r r
n
a J I rjuJ J_. r Q
PHONE NOCND ) a&r- _[LC) Q FAX NO(`Ip71 fie) 0
CONST. INSP. [ j C / O INSP. j j REINSPECTION [ j . PLANS REVIEW
F. A. [ ] F.S. [ ] HOOD [ ] PAINT BOOTH [], BURN P MIT [ j
TENT PERMIT TANK PERMIT [ j OTHER
TOTAL FEES: S vv (PER UNIT SEE BELOW)
Address / Bldg. # / Unit # Square Footage Fees per Bldg. / Unit
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13,
14,
15.
16.
17.
18.
19.
20.
Fees must be paid to Sanford Building Department, 300 N. Park Ave., Sanford, FI. 32771 Phone # -407-
330-5656. Proof of Payment must be made to Fire Prevention division before any further services can take
place. I certify that the above is true and correct and that I
will comply with all applicable codes and ordinances
of the City of Sanford, Florida.
kL
OW j
Sanford Fire Pr vention Division Applicant's Signature