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r CITY OE SANFORD PERMIT APPLICATION
n r
Ap Iicatiod # : /� Submittal.Date:
Job Address: / . value of Work: $
—7 lot
Parcel ID: Zoning: Historic District: i
Description of Wor ' ' rePVl!/O �1 s% /�.�.ru�ay>3FFo�� ���• ley.
......../.......�/..... ......................................................................
Permit Type: Building V Electrical ❑ Mechanical 0 )'lumbtng; ❑ Fire Sprinkler/Alarm ❑ Pool ❑ Sign ❑ �
Electrical: New Service — # of AMPS :Addrtroti/Alteration ❑ Change of Service ❑ Temporary Pole ❑
t
Mechanical: Residential ❑ Non -Residential ❑ Replacement' ❑ New ❑. (Duct Layout & Energy Calc Required)
Plumbing/ New Commercial: # of Fixtures # of Water.&Sewer. Lines_ # of Gas Lines
I
Plumbing/New Residential: # of ter:Closets Plumbing Repair - Residential ❑ Commercial ❑
Occupancy Type: Residential � Commercial ❑ Industrial ❑ Occupancy Use. Group(s):
Construction Type: �— # of Stories: # of Dwelling Units: � Flood Zone: (FEMA form required)
...................................... ................................................ ....
Property Owner: WI Contractor ; t..
Address: 136 W / S_f4U4a �/�' • Address - -
r,✓ F 771 nn//
Phoneu- ,T13/ E-mail:�/nelse�.La� C�T'l. rr L°'`' Phone: State License Number:
Bonding Company: /✓�i¢ Mortgage Lender:
Address: Address:
Architect/Engineer: Al _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. i_ n sl i l <3 i i
WARNING TO OWNER: YOUR FAILURE TO RECORD_,A NOTICE OF CQMIyNCEMENT MAY RESULT IN YOUR PARING 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.
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 dditional ermits required from other governmental entities such as water management districts, state agencies, or federal agencies.
Acce c f it is verification that I will notify the owner.of the property of the requirements of Florida Lien Law, FS 713.
9 zv ,a7
Slgnatu of wner/Agent Date Signature of Contractor/Agent Date
Xwner's eePrint Contractor/Agent's Name
ry State of Florida ate Signature of Notary -State of Florida Date
1IjEBI31E.-
MY COMMISSION # DD6299096
EXPIRES: February 25, -
"'For F- FI. Notary Discount Assoc' Co. - -
1 -800 -7 -NOTARY
Owner/Agent is _ Per on y Known to a or Contractor/Agent is _ Personally Known to Me or
r. ;I i. ni �,; ,,_1
Produced ID \ Produced ID
( In,1�:..:�T 3N l.Fi t)!li t. .
APPROVALS: ZONING: UTIL: FD: ENG: BLDG:
Special Conditions:
Rev 07.07
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 applicable restrictions and responsibilities.
OWNERS MUST PERSONALLY APPEAR AT THE BUILDING DIVISION TO SIGN THIS DOCUMENT
FSS 489.103 Disclosure Statement
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 supervision 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.
BY SIGNING THIS STATEMENT, I ATTEST THAT: (initial to the left of each statement)
Property Address:_
I, G✓�r draw•
performing the regi
0,/ 5Sf. W. ?27; .
con
.sf
, do hereby state that I am qualified and capable of
involved with the permit application filed.
Date
Identification 1) � ►`V -e -.S V( c4—, Sr
(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. 4/20/07)
I UNDERSTAND AND AGREE TO THE EXEMPTION PROVISIONS OF FLORIDA STATUTES 489.103
AS LISTED ABOVE.
1 HAVE ACCESS TO THE ADOPTED CODES.
I AM FAMILIAR WITH THE CODE PROVISIONS.
I HAVE ADEQUATE KNOWLEDGE AND QUALIFICATIONS TO SAFELY PERFORM AND DIRECTLY
SUPERVISE THE WORK.
THIS PROPERTY IS NOT AN APARTMENT, CONDOMINIUM OR RENTAL PROPERTY.
THIS STRUCTURE IS NOT BEING BUILT WITH MY INTENTION TO SELL, RENT, OR LEASE.
I UNDERSTAND THAT THERE IS NOT STATED A TIME FRAME TO SELL, RENT OR LEASE AN
OWNER BUILDER STRUCTURE WITHOUT BEING INVESTIGATED.
I UNDERSTAND THAT FOR ANY UN -LICENSED PERSON 1 HIRE, I MUST DEDUCT F.I.C.A.,
WITHHOLDING TAX, AND PROVIDE WORKERS' COMPENSATION INSURANCE.
Property Address:_
I, G✓�r draw•
performing the regi
0,/ 5Sf. W. ?27; .
con
.sf
, do hereby state that I am qualified and capable of
involved with the permit application filed.
Date
Identification 1) � ►`V -e -.S V( c4—, Sr
(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. 4/20/07)
CITY OF SANFORD HISTORIC PRESERVATION BOARD
APPLICATION FOR A CERTIFICATE OF APPROPRIATENESS
P.O. Box 1788, Sanford, FL 32772-1788
Phone: 407.302.5805 Fax: 407.330.5679
TO: THE HISTORIC PRESERVATION BOARD OF TWesidential
TY OF SANFORD, FLORIDA
❑ Downtown Commercial Historic District Historic District
❑ This application is filed in response to a notice from the Code Enforcement Department
ADDRESS OF PROPERTY: d y W,
Property OwnerIf
Signature: Print Name: Al, `// Cl 114ke"C',
Mailing Address: G(J/S/�C.t� Y. l d n g/•vdoe/ FL 92-7-21
Phone: j .-� �, _ 3 y 3 / Fax:
Applicant/Agent
Signature:
Mailing Address:
Phone:
ax:
-le Print Name:
I certify that all informatio ta' e t ' application is true and accurate to the best of my kn led e.
Applicant/Owner: Date: Z/ l% 7
Please use the attached cr' eria checklist as a guide to completing the application. Incomplete 4plications cannot be
reviewed and will be returned to you for more information. You are encouraged to contact the preservation planner at
407-330-5672 to make sure your application is complete.
Description of Proposed Work/Application Category: (Check all that apply)
❑ Site Improvements/driveway/walkway ❑ Storage shed ❑ Moving structures
Replacement windows or doors t4SS� ❑ Underskirting ❑ Awnings
❑ New con struction/additions ❑ Signs ❑molition
E3Roofs/gutters/downspouts ElAC/Mechanical Fences/Gatds/Pergolas
replacement siding/flooring/porch Paint ❑ Other
Completely describe the entire scope of work: all changes in material, color or location to the exterior of the building,
where on the property the work will occur and how the work will be accomplished. For large projects, an itemized list is
recommended. Attach additional pages if necessary.
/,l �
W
A Certificate of Appropriateness is valid for six months unless otherwise noted
OFFICIAL USE ONLY
Historic Preservation Board Meeting Date: Staff Review Date:
Application is Approved Approved with Conditions
Conditions:
Denied
%///////./%%
ZPAI, 0,• —
***This Certificate must be prominently displayed on the building when work is in progress***
Requirements for Certificate of Appropriateness Application
CITY OF SANFORD PERMIT APPLICATION �� /' � o
Application #: 09 �� c�+�' Submittal Date:
3
tJob_Addresa . S� Value of Work: $ 2
s: 141. Z� U
l �
Parcel ID: A- D Zoning: Historic District: h
Descrip ion of Work: C�41(� G+.17 n i �'�I S l2'CISS �ICIs� �h f`iltt geGis-Qd
/n ua Footage:
•Permit Type: Building ❑ • • • • �Ele`ctrical-SJ) Mechanical •❑ • • • • •Plumb g_I,I�S • • •Fire Sprinkler/Alarm ❑• • • • • • Pool •❑ • • • • • • Sign •❑
Electrical: New Service - # of AMPS Addition/Alteration ❑ Change of Service ❑ Temporary Pole ❑
Mechanical: Residential Non -Residential ❑ Replacement ❑ New ❑ (Duct Layout & Energy Calc. Required)
Plumbing/ New Commercial: # of Fixtures # of Water & Sewer Lines
Plumbing/New Residential: # of Water Closets --2--
Occupancy Type: Residential 2(1- Commercial ❑ Industrial ❑
# of Gas Lines
Plumbing Repair -Residential &( Commercial ❑
Occupancy Use Group(s):
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required )
pf'0
.................................................................................
•Pr6ty OvO-ne�1'.1 �Vt Ise Contractor: St
�AdUress: /%0 (/Ur Ste-/'r,c zo Address:
/ �h o t S
�pho 321^K3`-393 1 E-mail: �t/I/f%�M- �'IC/S � d Phone: State License Number:
Bonding Company:
Address:
Architect/Engineer:
Address:
Plan Review Contact Person:
Mortgage Lender:
Address:
Phone:
Fax:
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. 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.
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 additio ai permits required from other governmental entities such as water management districts, state agencies, or federal agencies.
Acceptance p it is itiication that 1 wil no ly the owner of the property of the requirements of Florida Lien Law, FS 713.
/d el
Sig�naftireofO ner/ gent Date Signature of Contractor/Agent Date
1__ ; (lt�-,-6.. Ale f�P�
Print caner/Aeeaihs Name Print Contractor/Agent's Name
Signature of Nofary-StaTe o'Fldf p MY COMMISSION VW 9096
o«oP EXPIRES: February 25, 2011
-AI.Y)`7 NOTgRY _ _ FI_ Notary Dismmt Ass.. Co.
Owner/Agent is _ Personally Known to Me or
Produced ID
APPROVALS: ZONING:
Special Conditions:
Rev 07.07
UTIL:
Signature of Notary -State of Florida Date
Contractor/Agent is _
Produced ID
FD: ENG:
Personally Known to Me or
BLDG:
OWNER BUILDER STATEMENT/AFFID"IT
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 applicable restrictions and responsibilities.
OWNERS MUST PERSONALLY APPEAR AT THE BUILDING DIVISION TO SIGN THIS DOCUMENT
FSS 489.103 Disclosure Statement
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 supervision 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.
/BY SIGNING THIS STATEMENT, I ATTEST THAT: (Initial to the left of each statement)
1
I UNDERSTAND AND AGREE TO THE EXEMPTION PROVISIONS OF FLORIDA STATUTES 489.103
AS LISTED ABOVE.
I HAVE ACCESS TO THE ADOPTED CODES.
I AM FAMILIAR WITH THE CODE PROVISIONS.
I
1 HAVE ADEQUATE KNOWLEDGE AND QUALIFICATIONS TO SAFELY PERFORM AND DIRECTLY
SUPERVISE THE WORK.
THIS PROPERTY IS NOT AN APARTMENT, CONDOMINIUM OR RENTAL PROPERTY.
THIS STRUCTURE IS NOT BEING BUILT WITH MY INTENTION TO SELL, RENT, OR LEASE.
I UNDERSTAND THAT THERE IS NOT STATED A TIME FRAME TO SELL, RENT OR LEASE AN
OWNER BUILDER STRUCTURE WITHOUT BEING INVESTIGATED.
I UNDERSTAND THAT FOR ANY UN -LICENSED PERSON 1 HIRE, I MUST DEDUCT F.I.C.A.,
WITHHOLDING TAX, AND PROVIDE WORKERS' COMPENSATION INSURANCE.
Property Address: 20 `t Al. A it ,S/
performing the y
Ale (S-( do hereby state that I am qualified and capable of
:sted c struction involved with the permit application filed.
I,-
el_)sD7
Date
Form of Identification
(Must be Photo 1D)
A violation of this exemption is a misdemeanor of the first degree punishable by a o imprison oI
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_ 4/20/07)