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CITY OF SANFORD PERMIT -APPLICATION
Permit # :
Date: �O! /b
r
Job Address:V
F
Description of Work: Re Dlace
I
Vvo,{-eK eG(*-iaj-
GxS t-�
Historic District: Zoning:
Value of Work: $ �5 O • od
Permit Type: Building Electrical
Mechanical Plumbing X_ Fire Sprinkler/Alarm PoQI .
Electrical: New Service - # of AMPS
Addition/Alteration Change of Service Temporary Pole
Mechanical: Residential Non -Residential
Replacement New (Duct Layout & Energy Cali. Required)
F.:. _
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 X Commercial
Industrial Total Square Footage:
Construction Tyne: # of Stories: # of Dwelling Units-. Flood Zone: (FEMA form required for other than X)
Parcel #: (Attach Proof of Ownership & al Description)
Owners Name & Address hlian Ben4dy ?Go -7 l -fa -\/\,/e] Ave �-Potd
Phone:
Bonding Company:
Address:
Mortgage Lender:
Address:
Architect/Engineer: Phone:
Address: Fax:
Application is hereby made to obtain a pemtit 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.
Cell.
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 require is of Florida Lien "wff S 713.
� 03
Signature of Owner/Agent Date S-!I-latureofCont:actor/Agent Date
Print Owner/Agent's Name
Signature of Notary -State of Florida Date
Owner/Agent is _
Produced ID
Personalh Known to Me or
\PPLICAI ION APPROVED BY: Bldg:
I Initial & Date)
�a cial Conditions:
Zoning:
un c,u ci7.,L s game
6L
Date
?• ; Commission #DD 163723
�..ae` Expires: Dec 20, 2005
9FoFe VQ,� Bonded Thru
mtraPtbPAce-A>lantic I}- A%C0 AWvn to Me or
(Initial & Date)
(Initial & Date)
FD:�
(ItNtial & Dat:
SECOND PARTY
PERMI`1C'A1JTIJORIZATION
11 1 v v , hereby authorize
PRINT License hold ' name only)
_ -7Q %(J��Z2� (..f_TMyi�l� Q / �" to obtain a permit on my
(PRINT Name(s) of authorized signer)
behalf under my license # cowp
TYPE PERMIT:
Building: HVAC: Other:
Electrical: Roofing:
Plumbing: Pool:
Owner(s): V/ V 11YAJ V _t( 7 �l I NI V_
Site Address:
Parcel #: - -
i V
X Date _r) j
(License holder's signature)
State of Florida, County of Volusia
This foregoing instrument was acknowledged before me this da of
KA
2001 by Vi 0 P011 Z_ , who is rsonally known
to me or has produced (type of ID) as identification
and who did take an oath.
( ignature(Jf Notary)
SEAL---
_«..............—..,...................•...........;
„a++ ; ANCY SKATES -WEARY
Commission # DD0134673
E)pires 7/21/2006
y;�,f ✓ o�'� Bonded n„ ���.
(gop 432 a25a} Florida Notary Assn., hr -
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