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CITY OF SANFORD PERMIT APPLICATION
Permit # : `
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Date:
Job Address: Q Q C J
Description of Work: rOf/ t l Il //'
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Historic District: A0b Zoning: Value of Work: $ ? S70 .00
Permit Type: Building El ectrigaI !G Mechanical Plumbing Fire Sprinkler/Alarm Pool
Electrical: New SerAMPSy/67
A
Addition/Alteration Change of Service X 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 p: (
Attach Proof of Ownership & Legal Description) Owners Name &
Address: r Phone:
Contractor
Name &
Address: IQ-00 G/kreopc Z.tZ'Z 2&. Se,.eA*
w/FL '1 Z773 State License Number: 4rC /,3ooiy'fi3 Phone & Fax: (
O%I 327-y`U 330-f 76 6/ Contact Person: Phone: Bonding Company:
Address: Mortgage
Lender:
t Address:
Architect/
Englneer:
N A 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 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 r5ei nts of Florida Lien Law, FS 713. Signature of
Owner/Agent Date ature of Contractor/Agent gent DatePrint Owner/
Agent's Name n t Con /Ag s Name Signature of
Notary -State of Florida Date Owner/Agent
is _ Personally Known to Me or Produced ID
APPLICATION APPROVED
BY: Bldg: Zoning: Wtj94 Date)
Special Conditions:
S1g'namreoo09ta
nS FLORENCE DE GRAVE Date a ....,. MY
COMMISSION
t DD 164280 IRES: November
12,2006 Contract6 T*
1 sC*X*JPMrWMe or Produced ID
Utilities: FD:
Initial & Date) (
Initial & Date) (Initial & Date)
El
To c
A SANFORD ELECTRIC CO., INC,
2522 S. PARK DRIVE
P.O. BOX 2026
SANFORD, FL 32772-2025