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C11'Y;OFSANFORD;PERMITAPPLICAIION+'=
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Perrult # :
Date: -;
ate:
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Job Address:
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Description of Work:
Historic District: Zoning:
Value of Work: S`.ae-�jr
Permit Type: Building Electrical Mechanical Plumb' Fs Sprinkler/Alarm PoQ1.
Electrical: New`Service — # of AMPS Addition/Altera n 4ee cc Tempottlry Pole
Mechanical: Residential Non -Residents eplacem New (Duct Layout & Energy CqS Required)
F..v.
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:yOO
Construction .Type: I_ # of Stories: N of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel 0: 219 I "1 _3b _ . T L__- 0 A -)nn (Attach Proof of Ownership & Legaescription)
Owners Name & Address- ..1— Q, 25 Y 4�
Phone: V a - 1
State License number: LJ "CL
Phone & Fax: FLiContact Person Phone:
Bonding Company:
Address: MIX
Mortgage Lender: N
Address: tJ A
Architect/Engineer: W A Phone: _ 1
Address: N Fax: N A
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.
N TI : In addition to the requirements of this permit, there may be additional restrictions applica to this perty at ma ound in the public records of
this county, and there may be additional permits required from other governmental entities such water dis , s to agencies, or federal agencies.
Acceptance of permit is verification that 1 will notify the owner of the property of the r irements A da w, FS 3.
Signature of Owner/Agent Date azure ontractor/Agen _ Date
Print Owner/Agent's NamePript Contractor. Agent's Nirrlp� , t
Signature of Notary -State of Florida
Owner/Agent is_ Personalh �ii
non to Me or
Produced IU
APPLICATION APPROVED BY: Bldg:
pecia! Conditions:
Date
Zoning:
:Initial & Date)
111" 4,211 � `�
Signature of No:ary-State of Florida Date
Contractor/Ag;-: is Yllerson.l.v Known to Me or
Produce :)
tii::::its: FD:
(Initial & Date) (Initial & Date) (hrtial & Dau
MIRINDA C. TURNER 11
EXPIRES: June 14,2W3
Duldad Thru Way Pubk UrderwriWS
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