HomeMy WebLinkAbout1201 W 25 StoqE-1-' V
R CITY OF SA14FORD PERMIT APPLICATION
Permit # a) _
e — 7-OS
Job Address: i O % W 2 5 v+
Date:
Description of Work: 2'A?Sr411 LiGLir —Fi7Sy ldQuo/Z>O'ytoO-S Historic
District: Avy Zoning: Value of Work: $ azo-00 Permit
Type: Building Electrical X Mechanical Plumbing Fire SprinMer/Alatm Pool 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 # 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 Dwell tg Units: Flood Zone: (FEMA form required for other than X) Parcel #:
Owners
Name & Address: Ci % G Contractor
Dame & Address: — .QGi't Attach
Proof of Ownership & Legal Description) rx /
78f Phone:
i-
errs
r L. s P 77 L' State License Number. LCC /,3CXj / 579.g Phone &
Fax: *1-.YXZ t_ Z 3fp /i y Contact Person: -' ev ZLC45, Phone: 9+7- f//7`azl% Bonding
Company. a/ q Address:
Mortgage
Lender- Address:
Architect/
Engineer: lv Phone:
Address:
Fax:
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 issuanceofapermitand, that all work will be performed to mat standards of all laws regulating construction in this jurisdiction. I understand that a separate permitmustbesecuredforELECTRICALWORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, and AIRCONDITIONERS, 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 constructionandzoning. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICEFORIMPROVEMENTSTOYOURPROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEYBEFORERECORDINGYOURNOTICEOFCOMMENCEMENT. NOTICE.
In addition to the requirements of this peradt, there may be additional restrictions applicable to this property that may be found in the public records of thiscounty, 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 requimpmgts of Florida Lien Law, FS 713 Signature
of Owner/Agent 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: - I '7 .g:
Initial
81 tke) Special
Conditions: 7.
ai- Date
Print
Contractor/Agent' m try-
S"AADate my COWISSION
i DD so -` EXPIRES: Match
23, 2008 o iin
Dutlget Nohnl'SNYltes Contractor/ geRi
is _ Personally Known to Me or Produced ID
Initial & Date)
Utilities: FD:
Initial & Date) (
Initial & Date)