1137 Old England Lp 12-1046Shcy'�
CITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Application No: l lo (4 Y° Documented Construction Value: $
Job Address: �-i "� of Histo is District Yes ❑ No ❑
Parcel ID: 6 ,9%c Zoning:
Description of Worm: I CAL: " '
Plan Review Contact Person:
Phone:
Fax:
E -mail:
Title:
Property Owner Information
Name �cGt�fS��ia t� j!�'E Phone: -a�'- �� 3
Street: - (C 2 Resident of property? :
City, State Zip:
Contractor Information
Name Aj7 M Phone: G1-�r�� -- 333
Street: NaNz) QC. Fax:
City, State Zip: r jG, d� . 'F LO
State License No.: E F w o it a )
'Architect/Engineer Information
Name:
Phone:
Street: Fax:
City, St, Zip: E -mail: _
Bonding Company: Mortgage Lender:
Address:
Building Permit ❑
Square Footage: 0
No. of Dwelling Units: _
Electrical Nil-`,
New Service -No. of AMPS:
Address:
PERMIT INFORMATION
Construction Type: No. of Stories:
Flood Zone:
Mechanical ❑ (Duct layout required for new systems)
Plumbing ❑
New Construction -No. of Fixtures:
Fire Sprinkler /Alarm ❑ No. of heads:
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 DIPROVEMENTS TO YOUR PROPERTY. A NOTICE
OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE
FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORRRECORDING 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 foum 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 requirements of Florida
Lien Law, FS 713.
The City of Sanford requires. payment. of a plan review fee. A copy of the executed contract is required in order
to calculate a plan review charge. If the executed contract is not submitted, we reserve the right to calculate the
plan review fee based on past permit activity levels. Should calculated charges exceed the documented
construction value when the executed contract is submitted, credit will be applied to your permit fees when the
permit is released.
Signature of Owner /Agent Date
Print Owner /Agent's Name
signature ofNotary -State of Florida Date
Owner /Agent is Personally Known to Me or
Produced 1D Type of ID
APPROVALS: ZONING:
ENGINEERING:
GOMMENTS:
Rev. 11.08
UTILITIES:
��
Signature of "/ntmctor /Agcnt Date
{ ' TV'\
Print CogRracloffgent's Nad}re
.t.-�
3 /a ho 1 l
Signature of
�.*� ^.'•,
LAURENRAJNAUTH
MY COMMISSION I EE 118072
`
EXPIRES: August 2, 2015
' p.... Bonded Thtu Notary publicUnderwriters
Contractor /Agent is L- Personally Known to Me or
Produced ID Type of ID
WASTE WATER:
BUILDING:
RESIDENTIAL SERVICES CONTRACT IIIIII I I II III IIIIIIIIIIIIIIIII
.5104UE14
CONTDATTEE, Cj :ACCOUNT NO �.- ,NO "CIJ SOURCE =
THERE IS NO FINANCE CHARGE OR COST (0% APR) ASSOCIATED WITH THIS CONTRACT-
ction 1. CustorrerJnf6'L'_._.
ADT Security Services, Inc ( "ADT ") f Customer Name u
Office Address 1" J (a
( "Customer" or "I" or or "my ')
69830 _Is {,acct: nd Dr
U to
(
Premises' Q ( 1 4 �, /
J 1 n YI t�
Address
eJ (C F ..
City ..G State:K ..ZIP
Tax Exempt No. Tax Expire Date m/Ell/E0
www.MyADT.com
1.800.ADT.ASAP® Protected Premises' O Traditional Phone O Other (Qualified) O Other (Non - Qualified)
(1.800.238.2727) Telephone
FREQUENCY, PRIOR TO THE START OF SERVICE. MY FIRST BILL/CHARGE WILL
(-
Alternate O Home ® Cell O Work Aternate . I O Home O Cell O.Work
615
'Telephone 1 Telephone 2 I
O Fill in if billing address is the same
Billing
ADDITIONAL INFORMATION
ONE -TIME LATE CHARGE ON EACH PAYMENT THAT IS MORE THAN TEN (10)
OF THIS CONTRACT, THERE IS NO
ABOUT NONPAYMENT, DEFAULT
DAYS PAST DUE, UP TO THE MAXIMUM AMOUNT PERMITTED BY LAW, BUT IN
PENALTY OR REFUND.
AND ACCELERATION.
NO EVENT WILL THIS AMOUNT EXCEED $5.00.
Address
1.11 1 1 111 m
City State .211,
IF FAMILIARIZATION PERIOD IS REJECTED INITIAL HERE _4;_�� (see Paragraph 14 of the Terms and Conditions for explanation)
EMAIL
LLLLLLJTTTTI
Communications Authorization: i authorize ADT to provide me with information and updates about the security system and new ADT and third -party
products and services to the contact information provided by me. I may unsubscribe or.opt out by emailing donotcontact ®ADT.com or by calling
888.DNC4ADT (888.362.4238). Initial here
Confirmation of Appointments: I authorize ADT to call me using an automated calling device to deliver a pre- recorded message to settconfirm
appointments and provide other information and n�ottiic� about the alarm system at the telephone number(s) provided by me. Initial here
Alarm System Ownership: O Customer -Owned ADT Owned
I ACKNOWLEDGE AND AGREE TO EACH OF THE FOLLOWING: (A) THIS CONTRACT CONSISTS OF SIX (6) PAGES, BEFORE SIGNING THIS CONTRACT, I
HAVE READ, UNDERSTAND AND AGREE-TO EACH AND EVERY TERM OF THIS CONTRACT, INCLUDING BUT NOT LIMITED TO PARAGRAPHS 5 AND 18 OF
THE TERMS AND CONDITIONS, (B) THE INITIAL TERM OF TH15- CONTRACT IS THREE (3) YEARS. (C) ADT IS NOT A SECURITY CONSULTANT AND CANNOT
ADDRESS ALL OF MY POTENTIAL SECURITY NEEDS. ADT HAS EXPLAINED TO ME THE FULL RANGE OF EQUIPMENT AND SERVICES THAT ADT CAN
PROVIDE ME. ADDITIONAL EQUIPMENT AND SERVICES OVER THOSE IDENTIFIED IN THIS.CONTRACT ARE AVAILABLE AND MAY BE PURCHASED FROM
ADT AT AN ADDITIONAL COST TO ME. I HAVE SELECTED AND PURCHASED ONLY THE EQUIPMENT AND SERVICES IDENTIFIED IN THIS CONTRACT, (D) NO
ALARM SYSTEM CAN PROVIDE COMPLETE PROTECTION OR.GUARANTEE PREVENTION OF LOSS OR INJURY. FIRES, FLOODS, BURGLARIES, ROBBERIES,
MEDICAL PROBLEMS AND OTHER INCIDENTS: ARE UNPREDICTABLE AND CANNOT ALWAYS BE DETECTED OR PREVENTED.BY AN ALARM SYSTEM.
HUMAN ERROR IS ALWAYS POSSIBLE, AND THE RESPONSE TIME,OF POLICE, FIRE AND MEDICAL EMERGENCY PERSONNEL Is OUTSIDE THE CONTROL.
OF ADT. ADT MAY NOT RECEIVE ALARM SIGNALS IF COMMUNICATIONS OR POWER IS INTERRUPTED FOR ANY REASON. (E) ADT RECOMMENDS THAT I
.MANUALLY TEST THE ALARM SYSTEM MONTHLY AND ANY TIME 1 CHANGE TELEPHONE SERVICE, BY CALLING 1.800.ADTASAP OR BY LOGGING IN TO
WW W.MYADT.COM. (F) THIS CONTRACT REQUIRES FINAL APPROVAL BY AN ADTAUTHORIZED MANAGER BEFORE ADT MAY PROVIDE ANY EQUIPMENT
OR SERVICES, AND IF APPROVAL IS DENIED, THEN THIS CONTRACT WILL BE TERMINATED, AND ADT'S ONLY OBLIGATION WILL BE TO NOTIFY ME OF
SUCH TERMINATION AND REFUND ANY AMOUNTS I PAID IN ADVANCE.
ADT Representative N,aamp -
$� Rep. License No. Rep. 1_
(If Required) ID No
Customer's Approval: Original Signature Required (Must match Customer Name in Section 1 above)
m
X Cif , Ai.�'
NOTICE OF CANCELLATION
I, THE CUSTOMER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION
OF THIS RIGHT. I ACKNOWLEDGE BEING VERBALLY INFORMED OF MY RIGHT TO CANCEL AT THE TIME OF EXECUTION
OF THIS CONTRACT AND RECEIPT OF THIS NOTICE.
1 Of 6 Administrative Copy 02011 ADT. All rights reserved. (06111)
:Section 2. Services to be Provided
FINANCIAL DISCLOSURE STATEMENT
THERE IS NO FINANCE CHARGE OR COST (0% APR) ASSOCIATED WITH THIS CONTRACT-
- - - --
A. NUMBER OF
(�OCF�CREDIT
��—
I Ax.
$
PAYMENTS FOR THE
t I
AMOUNT OF EACH PAYMENT IS
TOTAL OF PAYMENTS FOR THE INITIAL TERM IS
! (A, TIMES B.) (EXCLUSIVE OF ANY APPLICABLE TAXES, FEES, FINES
INITIAL TERM 15 36.
(T F
I (TOTAL MONTHLY SERVICE CHARGE FROM BELOW)
AND RATE INCREASES)
LATE CHARGE - PAYMENT IS DUE PURSUANT TO MY SELECTED BILLING
PREPAYMENT – IF 1 PREPAYTHE
SEE SECTIONS 2,7, 15 AND
FREQUENCY, PRIOR TO THE START OF SERVICE. MY FIRST BILL/CHARGE WILL
TOTAL OF PAYMENTS PRIOR TO
19 OF THIS CONTRACT FOR
BE SENT /MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IMPOSE A
THE END OF THE INITIAL TERM
ADDITIONAL INFORMATION
ONE -TIME LATE CHARGE ON EACH PAYMENT THAT IS MORE THAN TEN (10)
OF THIS CONTRACT, THERE IS NO
ABOUT NONPAYMENT, DEFAULT
DAYS PAST DUE, UP TO THE MAXIMUM AMOUNT PERMITTED BY LAW, BUT IN
PENALTY OR REFUND.
AND ACCELERATION.
NO EVENT WILL THIS AMOUNT EXCEED $5.00.
1 Of 6 Administrative Copy 02011 ADT. All rights reserved. (06111)
RESIOENTIAL SERVICES CONTRACT
5104UE14
CONTRACT DATE rL✓_6 `< ' NO m
1� ACCOUNT SOURCE
NO
s • •- a •-• • -•
`" '
Standard Monthly Service, Burglary
Monthl'Sem ceChar e
1 Y 9
I -. t c
O Initial /Annual Recurring Municipal Fee billed separately
`, (Subject to change based on local law) :.
— —
InitiaVAnnual Fee
—
q —
Service includes: Customer Monitoring Center Signal
Receiving and Notification Service for Burglary,
Manual Fire Manual Police Emergency
O Customer to obtain and pay for initiallannual um
mu-a6 ,
alarm use permit Failure to pbtaln'and provide AUT with
the municipal alarm us permltfegismation number uld
co
and
result in no municipal fire/ lice response to an alarm"
fr m the pr' is6 andldr a' fine.
O Standard Monthly Service,. FlrelSntokc'Detection
5��eerrvv"��ceindudes:,Customer Monitoring Center:: Signal:_
I{ecelying Notification service for Fire, Manual Fire
Municipal- :Eledrical.Perm_it Fge
electiical
and
and Manual Police Emergency
O Customerto obtain permit
O Carbon Monoxide O Flood O Low Temp
n/.r...
Installation Polce I .t
1 L
0 medical Alert
$
Taxable Amount
*tl fewatch Cellguard'
��/� } } }rrr l}
Non - Taxable Ahiount
O S ntyLink' --
Extended Limited Warranty/Quality Service Plan (QSP)
$
$ �LT
J
1
Connection Fee —" —r— --
Admin Fee —
— —
O Guard Response Service
$
Sales Tax on Installation* J
O Monthly Recurring Municipal Fee
(Subject to change based on local law)
O Customer to obtain and for
Total Installation Charge*
pay
municipal alarm use permit
r
—�
O Other
$
Deposit Received
Total Monthly Service Charge
c) t.
Balance Due upon Installation*
*If applicable sales tax not shown, it Will be added to the first invoice.
Section • • to be Installed
- Control n /t i , o�ll , Se�SO Oe�it¢a�`, Owe``, �i`L ��L \A a eta \Se G �Se$a /
',
aa\1
e
Panel( 'o�S �\oo �See�o.�itiY�o
�o; po. 3T` d`O /6�a0e;'�e0e caOevSa�oa, C�j'p0ui'POtr'POpg�; PO/ Comments.
Pack ge Name:
Includes:
Foyer ^�
Living Room—
f
r �
f
I � �
i
► __�
_
I
I� -�
J
Family Room
^—- - --
__
'Office
Dining Room
Kitchen
I
II
Hallway
Master Bedroom
Master Bath
J
Bedroom 2
Bedroom 3
Bath 2 #
Basement
_!-
Garage
J
J
jjj
I
Price Per P(ece
Totals
I
`' .
E�= EExxist�ing�Equiipme�nt
�I
Estimated Iristallation Start Date
INSTALLER NOTES S e e
2 Of 6 02011 ADT. All rights reserved.: (06/11)
r:
PERMIT #
PROPERTY OWNER
CONTRACTOR
DESCRIPTION OF WORK
CITY OF SANFORD INSPECTION CARD
FAX/EMAIL RESIDENTIAL PERMITS ONLY
INSPECTION REQUEST LINE - 407.688.5151
*MANUFACTURE SPECIFICATIONS OR INSTALL INSTRUCTIONS N
TO BE ON SITE*
BUILDING
ELECTRICAL
PLUMBING
HVAC*
* Florida energy code requires
verification of matched systems
FINAL SIDING
TEMP POLE
ROUGH -IN / PRESSURE TEST
ROUGH IN
FINAL SOFFIT /FASCIA
ROUGH IN
SEWER TEST
FINAL
RE - ROOF
FINAL
IRRIGATION
SHEATHING /DECKING
CHANGE OF SERVICE
FINAL
DRY -IN
INSULATION
MITIGATION AFFIDAVIT
FINAL
INSPECTION CARD SHALL BE DISPLAYED ON STREET SIDE OF LOT
DO NOT REMOVE CARD UNTIL FINAL INSPECTION IS APPROVED
SANITARY FACILITIES REQUIRED ON SITE
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS
TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED
AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU
INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT."
NOTICE OF COMMENCEMENT REQUIRED: YES ' NO
BUILDING OFFICIAL � rn - ,' TECH INITIALS , s ISSUED 13 • w • 1 Z
Issued permits must have an approved inspection within 6 months of the date of issuance or they will expire.
An extension must be requested in writing, approved and paid for prior to expiration.