HomeMy WebLinkAbout107 London Fog WayCITY OF SAJVFORD PERMIT APPLICATION
Permit # : 333 6,
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II 11 Date: �
Job Address: �i7Z L(eipyN����
Description of Work:
Historic District:
Permit Type: Building Elecmcal Mechanical ✓Plumbing Fire Sprinkler/Alarm Pool
Electrical: New Service - # of AMPS
Add ition/Alteration
Change of Service Temporary Pole
Mechanical: Residential ✓ Non -Residential
_ Replacement
New (Duct Layout & Energy Calc. Required)
Plumbing/ New Commercial # of Fixtures
,t of Water & Sewer Lines
# of Gas Lines
Plumbing/New Residential , of Water Closets
Plumbing Repair - Residential or commercial
OccupancN Type: Residential �� Convrnercial
Industrial
Total Square Footage: -10
Construction Type. # of Stories:
# of Dwelling Units:
Flood Zone: (FEMA form required for other than X)
IC
Parcel # 33 - / r 3D' St3- C>pno`
C'>37 C>
(Attach Proof of Ownership & Legal Description)
Owners Name & Address: �'ej/- l e� tr 1 L1 C _Q �S� 1 y% L-i>*,to ] F�Ot
,�30K-'QVCd ��- '�Z�'-z Phoue: Cib%-
Coatractor :Name & Address
��� rc� I ►�{t
State License Number:C�CC.-
A OSCLIZ bT
Yhooe & Fa Contact Person: 2 1 CeM4.Q�Phoue-lv�' 3ZZ-779�
Boadiag Company: T
Address.
Mortgage Lender:
Address:
Architect/Engiaeer Phone:
Address: _ Fax:
Applicadon 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 pe -mut, there may be additional restrictions applicable to this property tha y be found in the public records of
this county, and there may be additional permits required from other governmenlial entitAeufoeo;f6KC9tor/Agent
stricts, state agencies, or federal agencies.
Acceptance of permit is verification that I will notify the owner of the property of the reFS 713.
Signature of Owner/Agent Date Date
Print Owner/Agent's Name
Signature of Notary -State of Florida Date
Owner/Agent is _ Personally Known to Me or
_ Produced ID
APPLICATION APPROVED BY: Bldg:
(Initial & Date)
Special Conditions:
Zoning:
P ontractor/Agent's Nam
2S 167
Signature of Notary -State of Florida Date
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Contractor/Agent is <"'cm��T%ow� �
_ Produced — <Y 16, G
Utilities: { Dc> • `
(Initial & Date)
& Date)
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