1411 Park Ave 17-1662; ELECTRICAL7. I.._ CITY OF SANFORD
BUILDING & FIRE PREVENTION
Dr' 0101 PERMIT APPLICATION
h5' /
Application No: ri (.0 0
o
Documented Construction Value: S
Job Address: /% , /`-cr Historic District: Yes No
Parcel ID: Residential IK Commercial
Type of Work: New Addition Alteration Repair Demo Change of Use Move
Description of Work:
Plan Review Contact Person:
Phone: / U%J- / —c Vz Fax:
n Title: ;15 5,=
Email:r7'dr.-e ba3` i EYE
Property Owner Information
Name TG? e , 5 Phone:
Street: ref _ e c>,i ;; t Resident of property?
City, State Zip:
Cont`ractor Information
Name ' r - Phone:
Street: Fax:
City, State Zip:
Name:
Street:
City, St, Zip:
Bonding Company:
Address:
State License No.: L'YZ /':
Arch itectlEngineer Information
Phone:
Fax:
E-mail:
Mortgage Lender:
Address:
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.
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.
FBC 105.3 Shall be inscribed with the date of application and the code in effect as of that date: 5'h Edition (2014) Florida Building Code
Revised: June 30, 2015 Permit Application
t
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 requirements of Florida Lien Law, FS 713.
The City of Sanford requires payment of a plan review fee at the time of permit submittal. A copy of the executed contract is required
in order to calculate a plan review charge and will be considered the estimated construction value of the job at the time of submittal.
The actual construction value will be figured based on the current ICC Valuation Table in effect at the time the permit is issued, in
accordance with local ordinance. Should calculated charges figured off the executed contract exceed the actual construction value,
credit will be applied to your permit fees when the permit is issued.
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.
Signature of Owner/Agent
Print Owner/Agent's Name
Date
Signature of Notary -State of Florida Date
ignature ontmctor/Agent Date
Print Con for/Agent's Name t)
MY COMMISSION i0 FFF 9 6284
EXPIRES! March 23, 2020
Bonded 7hru yortN; Ptihiic umle Y:c
Date
Owner/Agent is Personally Known to Me or Contractor/An of
rsona y Frio to Me or
Produced ID Type of ID Produced ID ID U
BELOW IS FOR OFFICE USE ONLY
Permits Required: Building Electrical Mechanical Plumbing Gas Roof
Construction Type:
Total Sq Ft of Bldg:
Occupancy Use: Flood Zone:
Min. Occupancy Load: # of Stories:
New Construction: Electric - It of Amps
Fire Sprinkler Permit: Yes No
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
of Heads
UTILITIES:
FIRE:
Plumbing - # of Fixtures
Fire Alarm Permit: Yes No
WASTE WATER:
BUILDING:
Revised: June 30, 2015 - Permit Application
SE 0 r 2017
LIMITED POWER OF ATTORNEVt,,
Altamonte Springs, Casselberry, Lake Mary, Longwood, Sanford,
Seminole County, Winter Springs
Date:
I hereby name and appoint:
an agent of:
Name of Company)
to be my lawful attorney -in -fact to act for me to apply for, receipt for, sign for and do all things
necessary to this appointment for (check only one option):
The specific permit and application for work located at:
Street Address)
Expiration Date for This Limited PoweL of Attorney: 4/,,/,_
License Holder Name: , a &6's
State License Number:
Signature of License H
STATE OF FLORIDA
COUNTY OF Se_m,, n6U
The foregoing instrument was acknowledged before me this 0 day of ,
20_3- , by )._... G who is personally known
to me or o who has produced as
identification and who did (did not) take an oath.
T
Signature
Notary Seal)
Print or type name
NICOLE D.AMMON Notary Public - State of C—`0-k6 0.
Nowy PUNIC • SIM of no" Commission No. F ()S \5G qMyComm. Expf ss Nov 15.2017 0
Conwission 0 FF 051500 My Commission Expires: NC5-,1 \S 2bQ
Bonded T1=0 NatbW Nfty
IIMP
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Rev. 08.12)