HomeMy WebLinkAbout250 W Lake Mary BlvdCITY OF SAIVI'ORD PERMIT APPLICATION
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Permit No.: CL b _�?l Date:
Job Address: . y ':a -o to_ lC • k4uv 6&1f1 a -
Permit Type: .✓ Building Electrical Mechanical _ Plumbing Fire Akarni/Sprinkler
Description of Work:
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Additional Information for Electrical & Plumbing Permits
Electrical: Addition/Alteration Change of Service T Temporary Pole —New AMP Service (# of AMPS __,)
Plumbing/Residential: Addition/Alteration _ New Construction (One Closet Plus Additional)
Plumbing/Conimercial: Number of Fixtures Number of Water & Sewer Drainage Lines Number of Gas Lines
Occupancy Wylie: __
Type of Construction;
Parcel No.: / I.-
Residentialt ommercial _industrial Total Sq letg: Value of Work: $ 4 2U
Owner/Address/Phone:
]Flood Gone: Number of Stories: Number of Dwelling Units:
Contractor/Address/Phone: M714(160 S
- 33
(Attach Proof of Ownership & Legal Description)
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l ll�� 'rF%✓Nz c= /�/G( �Q• &Altjl�rf� State License Number:
Contact Person: _ 1)111Ckf�=i G6_ /iloolat Phone & Fax Number: �%l�� 5� ".�� dJ.� � 'D lJ(-6
Title Holder (If other than Owner):
Address: ------
Bonding
Bonding Company:
Address:
Mortgage Lendcr:
Address:
Architect/Engineer
Address: i%�
Phone No.:l%/-'
Fax No.:
Application is hereby made to obtain a permit to do the work and installations as indicated. Fcertify 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 coustructiocc
in this jurisdiction. I understand that a separate permit crust 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 "1'O 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
foiucd iii the public re(lords of this county, and there may be additional permits required Brom 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 Florida Lien Law, FS 713.
Signature of Owner/Agent Date Silnatur of Contractor/Agent Date
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Print Owner/Agent's Name Print Cc nt of c A ant's Narue
Signature of Notary -State of Florida Date Signature -or-Notary-State of Florida Date
Owner/Agent is _
Produced ID
Personally Known to Me or
LINDA D� EVANS
Notary Public, State of Flori(J8
My cornmv exp. Janj�7vfJt7 .._.
Comm. No. 06806
Coutractor/Agent is _ ( Personally Known t Me or
Produced ID —_
APPLICATION APPROVED BY: ` �' Date:
Special Conditions:
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JAMES T, MELVIN ARCHITECT
206 EAST FIRST ST,
SANFQRD, FLORIDA 32771
407-321-5444 FAX, 407-321--9089
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