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Permit # : ( J
Job Address:
Description of Wor
Historic District:
Zoning:
�03D:340
CITY OF SANFORD PERMIT APPLICATION
Date: q
Value of Work:
Permit Type: Building Electrical X Mechanical Plumbing Fire Sprinkler/Alarm Pool
Electrical: New Service — # of AMPS L9__ 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 # of Gas Lines
Plumbing/New Residential: # of Water Closets Plumbing Repair — Residential or Commercial
Occupancy Type: Residential Commercial Industrial Total Square Footage:
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel #: (Attach Proof of Ownership & Legal Description)
Owners Name & Address: F N C' -s L_ 52 rr:C21
Phone:
Name & Address: P A
Phone & Fax:'/ I `
Bonding Company: _
Address:
Mortgage Lender: _
Address:
Architect/Engineer:
Address:
q!51 Contact Person:
State License Number:
Phone:
Fax:
r-L3DAC
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 ofthe 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 ofthis 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 requirements of Fl da n Law, FS 713.
Signature of Owner/Agent
Owner/Agent's Name
Signature of Notary -State of Florida
Owner/Agent is Personally Known to Me or
Produced ID -
APPLICATION APPROVED BY: Bldg: _
Special Conditions:
Date
Date,.
Zoning:
Signature of Contractor/ nt Date )
1c TT q 301
=ofN66ary-Staie
ame
f Florida Date
r►x" Notary public Stets of Florida
Pamela S Temus
Contractor/Agent is .Re o � tgNl�btnmissiort Dp437139
Produced ID o 081.0712009
(Initial & Date) (Initial & Date)
Utilities:
FD:
(Initial &-Date) (Initial & Date)