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Permit # : L
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Job Address: 5t,
CITY OF SANFORD PERMIT APPLICATION
Date: J�
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Description of Work:
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Historic District: Zoning:
Value of Work: $
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Permit Type: Building Electrical
Mechanical Plumbing Fire Sprinkler/Alarm Pool
Electrical: New Service — # of AMPS
Addition/Alteration Change of Service Temporary Pole
Mechanical: Residential V Non -Residential
Replacement New (Duct Layout &Energy Calc. Reggired)
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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 & Le I_Description)
Owner Name & Address: lei:- V 1-01„ 9 a 0. a(�
Phone:1W -Y3 F9
Cop{ractor Name & Address:
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Phone & Fax:
Bonding Company:
Address:
'stortgage Lender:
Address:
ArchitecVEngineer:
Address:
J r s tate
JrnseNumber: [-/T(Z 0 fcXd fly
Contact Person: I <-FJirt Phone: O 7' 3,4'p-
Phone:
Fax:
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 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 requirem of F r n Law, FS 713.
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Signature of Owner/Agent Date Signature of ontrac r/A Date
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Print Owner/Agent's Name Prin for/A ent's Name n
li i. I
Signature of Notary -State of Florida Date Signature of Notary -State of Florida Date
Owner/Agent is _ Personally Known to Me or
Produced ID
APPLIC.A TION APPROVED BY. Bldg:
(Initial & Date)
Special Conditions:
Zoning:
Contractor/Agent is _a' Personally Known to Me or
Produced ID
(Initial & Date)
LUCY L. HISE
ppy,OMMISSION #fQP, 164328 JR
(InitLa(MeStonuary24,tial Pate)
Bonded Thru Notary Public Underv+r' ers C
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