100 Oakridge Ct; 17-2299; roofCITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Application No:
Documented Construction Value: S 5,290.00
Job Address: 100 OAKRIDGE CT Historic District: Yes No
Parcel ID: 11-20-30-510-0000-1250 Residential X Commercial
Type of Work: New Addition Alteration Repair Demo Change of Use Move
Description of Work: 2300 SO. FT. SHINGLE ROOF REPLACEMENT
Plan Review Contact Person: S VO4-LE-1 Title:
Phone: '52-493-Fax: Email: r-0Qr%rto,Ls_o/x.n QP .
Property Owner Information
Name PAUL C CIPPARONE TRUSTEE FBO Phone: MEL: 407-810-4726
Street: 1525 INTERNATIONAL PKY #107
City, State Zip: LAKE MARY, FL 32746
Resident of property? : NO
PHYLLIS A. SIMMONS
Contractor Information
Name SIMMONS PERFORMANCE ROOFING, INC. Phone: 352-483-9598
Street: 22335 HORIZON VISTAS DRIVE Fax: 352-483-9599
City, State Zip: EUSTIS, FL 32736
Name: N/A
Street:
City, St, Zip:
Bonding Company: N/A
Address:
State License No.: CCC1325617
Architect/Engineer Information
Phone:
Fax:
E-mail:
Mortgage Lender: N/A
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.
FRC 105.3 Shall be inscribed with the date of application and the code in effect as of that date: 5111 Edition (2014) Florida Building Code
Revised: June 30, 2015 Permit Application
V
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 tile issuance or a permit and that all work will be performed to
meet standards of all lakes 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 relgitlating Construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF CONIMENCEMENT MAY
RESULT IN YOUR PAYINGTWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COM.MENCEMENT MUST TIE RECORDED AND POSTED ON THE JOB SITE, BEFORE, THE FIRST
INSPECTION. IF YOU INTEND TO 0111"AIN F INANCINc. CONSULT WITH YOUR LENDER
OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEM.E, NT. NOTICE:
In addition to the I-CqUirC111C!"ItS of this permit, there may, be additional restrictions applicable to this property
that may be found in [lie public records Of this County; and there may be additional permits required from
other governmental entities such as water management districts, state agencies, or fiedcral agencies. Acceptance
of permit IS verification that I will notify the owner of the property ol'the requirements of I-lorida Lien
Law, I'S 7 In). The
City ofSanford requires payment of a. plan review, fee. A copy ref the executed contract is required in order to
calculate a plan review charge. lithe executed contract is not submitted, we reserve the right to calculate the plan
review ('cc based on past permit IlctiVil-Y ICVCIS. Should calculated charges exceed the documented MlSh'
LIC6011 Value when the executed contract Is submitted. credit will be applied 10 Your permit fees when the permit
is released. 711-
1117 Si
naturenCOtatterfr gent Da w ptint
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hjycoMMISSION #FF9$M 24
EXPIRES: April 24.2020 B0nd0dThrUN0tWPUWLh_
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vner/Auent is -1-personally Knov,in to ;vie or Prodl.]
Ud I D __ Type of* 11) APPROVALS:
ZONING: UTILITIES: EN
G INE-E*R I NG: FIRE: COMMENTS:
Signittirc
of-ontincto—r/Agmi the PHYLLIS
A. SIMMONS hint
N=c SHIRLEY
CONLEY NIYCOMMISSION
OGG99197 EXPIRES: June
30,2021 Contracior/Agent
is _)6 B rsonally Krimvii () I'vic or Produced ID
T\1PQ1a_W_ WASTE WATER:
131.11ILDING:
Stan be
i I Iser i hed wi I I I I I ic date ofapp I icai ion and the code in i e11cc I is oft hat (Inic I Cut] c _2 0 1 it 1: 13C) 731. 13 5( i 1( 6 1Florida S tu ILt US REV 07.
14
SCPA Parcel View: 11-20-30-510-0000-1250 Page 1 of 1
Property Record Card
lust/Markel ie
tnrlon'CfA
Parcel: 1 1 -20-30-510-0000-1250
Owner: CIPPARONE PAUL C'i"RUSTEE FBO
nasnu,cota rry r vn
Property Address: 100 OAKRIDGE CT SANFORD, FL 32773
t I
Parcel Information Value Summary
I , Parcel 111-20-30-510-0000 1250 17 Working 2016 Certified1A. I
Owner CIPPARONE PAUL C TRUSTEE FBO I
lues Values
I . ___..__ _._.__ -----
Property Address 100 OAKRIDGE CT SANFORD FL 32773
y I Valuation Method Cost/Market Cost/Market
I
Madmg 1525 INTERNATIONAL PKWY #1071 LAKE MARY FL 32746 I
Number of Buildings 1 1
Subdivision Name 1 HIDDEN LAKE VILLAS PH 5
Depreciated Bldg Value S74,440 S66,501
Tax District S1-SANFORD 1 '
Depreciated EXFT Value
f-.__
DOR Use Code 0103-TOWNHOME
Land Value (Market) S20,000 16.000
Land Value Ag
I Exemptions!
Val 194440 182501
77U
00
0)
04 2 38. Portability Adj
48 38. q8 38 4f save our Homes Adj $0 so
63.48 37.83 Amendment 1 Adj so
38.33
P&G Adj so so
00 T Assessed Value S94,440 $82,501
Tax Amount without SOH: $840.00
t--•
O
i 2016 Tax Bill Amount $840.00
Tax Estimator
LP
1.72 3 Save Our Homes Savings: $0.00
Does NOT INCLUDE Non Ad Valorem Assessments
y Seminole County GIS.
Legal Description
LOT 125
HIDDEN LAKE VILLAS PH 5
PB 28 PGS 81 TO 83
Taxes
Sales
Land
I Method Frontage Depth is Units Price F Land Value
LOT 0.00 0.00 1 $20.000.00 $20,000
Building Information
t Is Bed1bath count incorrect"? Click Here.
Year Built I j
Description Fixtures Bed Bath Base Area Total SF living SF j Ext N/all (j Adj Value Repl Value AppendagesyActuailEffec6ve -_-_.___......__..._
L.__........_..---J _
1 SINGLE 1985 6 2 2_0 1,116 1.558 1,116 CB/STUCCO S74,440 $86,558 Description Area
FAMILY FINISH____ _.
GARAGE
426.00
FINISHED
OPEN
PORCH 16.00 I
FINISHED
Permits
Extra Features
MtpJ/parceidetail.scpafl.org/ParcelDetaillnfo.aspx?PID=11203051000001250 May 16, 2017
SIMMONS PERFORMANCE ROOFING, INC.
22335 Horizon Vistas Drive, Eustis, FL 32736
Ph: 352-483-9598 / Fax: 352-483-9599
roofin bysimmons@aol.cotn
LIC# CCC 1325617
CONTRACT/PROPOSAL"'
Mel Bernstein DATE: 7/13/17
407-810-4726 Contract #R17-DV-071310-RR
met@mbrealpro.com Shingle Color Choice:p 1>
Vent Color Choice: Black. White, or rowywt
7(113: 1 /I(1 Onkrid?e Cvurt, Balr/c rd - SlritrrYle Roof Replacement (5:12 Pitch) III LG
Install a new Lifetime Architectural shingle roof according to rtrantifacturer's reconittiendertions and the 2014 Florida Building Code
1) Obtain the permit and file the notice of commencement as required by local codes.
2) 'Remove the existing single layer shingle roof down to the decking. Examine the exposed deck for
damaged/rotted wood and 2replace as necessary (see ADDITIONAL COST below).
3) Re -nail the decking using 8-D ring shank nails to ensure conformance to the Hurricane Mitigation Retrofit
Manual (Based on F. S. Chapter 553.844).
4) Install a new mechanically -fastened roofing underlayment (301b Gorilla Guard: [FLY 16226] or comparable) as a
secondary water barrier, using Simplex nails.
5) Install new plumbing pipe flashings (Ix 1-1/2", 2x2", 10" ),1-vents (3x l 0"),white eave drip (19x2-1 /2"),
and ridge vents (4) with end plugs (2).
6) Instal l up to 2300 sq. ft. (includes standard w-aste calculations and I bundle of ridge caps) of new Lifetime
Architectural shingles (Owens Coming Oakridge [FL#106741} using 1-1/4" barbed roofing nails.
7) Remove and haul al I job -related debris.
8) Provide a ten (10) year warranty on our workmanship under normal weather conditions and use.
9) Schedule a complimentary Wind Mitigation Report for homeowner insurance purposes ($100.00 Value).
Completed report with pictures to be e-hailed to homeowner.
ESTIMATED COST* (SEE ADDITIONAL COST BELOW)
Price reflects cash discount. Add 4% to total cost if paying via credit card
S 5,290.00 * *
Balance is due upon final furnishing
AODl"I 1nNAL°;COST'
1} Roofs %pithmorc than one Mayer of rtw}rn wdl be removaltthe cost t?f $30.00`par square; plus, the cost ofhaulmg the„a dritonaGiehris.
2) R6tted wood re ficcinent.and a _r`icket;builds Fvill,be p rfortnci avan aildi`ftonal,cost of.$30;OOpermamhotii plus the°coseaf mttteti iIS,
If you accept the terms above, please sign and date below and return a cope to us. fit doing, so, you accept responsibility for the removal and re -attachment ofany roof - mounted
equipment (inchtdes, but is not limited to, solar panels and satellite dishes), and far secunng of items on the walls and ceilings of the above -rimed property, with the reasonable
expectation of personnel walking on the roof and mechanically fastening roofing materials. Installation of roof=mounted equiptem may void our workmanship warranh;
werecommend attaching satellite dishes to the facia rather thanthe decking. Contract isbinding unless cancelled within 72 hours of signing. A signed/dated lien information sheet and original,
signed notice of Commencement Gie prior to commencement of this project. If requested, a Lieu Release will be e-mailed upon receipt of final
payment. "r—must t o- '`
AUTHORIZED
SIGMA RE: t
DATE: 7114 f I CONTRACTOR: = - DATE: Steven " ntions.
reside CO.
tIPLT710A'RFrltA1N'711h.'
PROPERTY01 sthiitOVS=PERFpRAIfiiVCE'R00JIIN'ii 1h'6:
i 11111111111111113111 1111111111 1 111i
THiS INSTRUMENT PREPARED BY:
Name: SIMMONS PERFORMANCE ROOFING, INC.
Address: 22335 HORIZON VISTAS DRIVE
EUSTIS, FL 32736
NOTICE OF COMMENCEMENT
Permit Number,
Parcel ID Number, 11-20-30-510.0000-1250.
n!'L,( iFuii — A-
EC"t;`i' f.IL.L.i_ LEfiK'
S t 2017072927 t) (
r III.- r I f 11"
ECON)D) B !;,':till ; L,tl The
undersigned hereby gives notice that improvement will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the foiloWng
information is provided in this Notice of Commencement. I.
DESCRIPTION OF PROPERTY: (Legal description of the property and street address if available) LOT
125 HIDDEN LAKE VILLAS PH 5 PB 28 PGS 81 TO 83 100
OAKRIDGE CT, SANFORD, FL 32773 2.
GENERAL DESCRIPTION OF IMPROVEMENT: ROOF
REPLACEMENT 3.
OWNER INFORMATION OR LESSEE INFORMATION IF THE LESSEE CONTRACTED FOR THE IMPROVEMENT: Name
and address: PAUL C CIPPARONE TRUSTEE 1525 INTERNATIONAL PKY#107, LAKE MARY, FL 32746 Interest
in property: OWNER Fee
Simple Title Holder (if other than owner listed above) Name: 4.
CONTRACTOR: Name: SIMMONS PERFORMANCE ROOFING, INC Phone Number: 352-483-9598 Address:
22335 HORIZON VISTAS DRIVE, EUSTIS, FL 32736 5.
SURETY (If applicable, a copy of the payment bond is attached): Name: Address:
Amount of Bond: 6.
LENDER: Address:
Phone
Number: 7,
Persons within the State of Florida Designated by Owner upon whom notice or other documents may be served as provided by Section 713.13(1)(a)7., Florida Statutes. Name
Phone Number: 8.
to addition. Ovmer designates to
receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Phone number: 9.
Expiration Date of Notice of Commencement (The expiration is 1 year from date of recording unless a different date is specified) WARNING
7O OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED
IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13, FLORIDA STATUTES, AND CAN 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
COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. t-
si t.r u((`ssiscra W55,;c, et:i Y.lIIYS or Lo..ea'z n;.;
ti9.^:eti Olt,czr(ire nnPn caortt.!anagp: ) Rini NvmO Ynd Nov,po ygnatorj c Ti7elDtace) State
of 1t a County of _ _ 7 (ab— The
foregoing Instrument was acknowledged before me this t ' ) day of CJ l .20 by- \
lam-.iJncuiyy- s Who
is personalty known to me OR i:•
InFC of tiff So0.T 1YJtY) i2nl4m}ni who
has produced Identification U typo of identification produced: CfRT'
4Et)LOr ti C.l, AtiU(}
FCt Tf LCItDf notary`
stanatur04..-----'-
BIRONN.
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y} tgr
ptPlttES, O
PU`J 13
111 _
City of Sanford
Building & Fire Prevention Division
Re -Roof Permit Card
PERMIT NO. , 7 "00 01 A2 / ISSUE DATE: _
CONTRACTOR:
JOB ADDRESS: /00 oator 1041
TYPE OF WORK:
PROTECT FROM WEATHER
Post this Permit and all required documents in a conspicuous place outside
Digital Photographs are required - please follow re -roof policy and procedures guide
All trash, debris and dumpsters must be removed from job site at final inspection
Permit expires six (6) months from date of issue
ROOF
INSPECTION TYPE APPROVED REJECTED INSPECTOR
FINAL ROOF T I
FAILURE TO FOLLOW THE RESIDENTIAL RE -ROOF POLICY & PROCEDURES WILL RESULT IN A FAILED INSPECTION, A RE -INSPECTION FEE
AND MAY REQUIRE AN AFFIDAVIT, SIGNED AND SEALED, FROM A REGISTERED FLORIDA DESIGN PROFESSIONAL
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: 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. FBC 105.3.3
REVISED: 4-17 Inspection Line 407.792.6069 or 855.541.2112
TO SCHEDULE AN INSPECTION:
Dial 407.792.6069 or 855.541.2112
Provide the items requested during the message
The type of inspection requested must be scheduled under the appropriate permit type
Follow the prompts
PLEASE NOTE: Inspections scheduled by 3-.Kp.m. will be conducted the
next business day. If you experience difficulty, please call 407.688.5150
Monday - Thursday 7:30 am - 5:30 pm for assistance.
AUTOMATED INSPECTION SYSTEM CODES
Final Roof Inspection Code III
Inspection Policy & Procedures
A Final Roof Inspection is the only inspection required for Residential
Single Family, Townhouse, Mobile Home, Apartment and/or Condominium) Re -Roof Permits.
The Following is required to be provide on the job site:
Permit Card, posted in a conspicuous and weatherproof location
Completed Residential Re -Roof Scope of Work
Completed and Notarized Inspection Affidavit
All Florida Product Approval and Corresponding Installation Instructions
Product Approval shall match what is on the scope of work)
Digital Photographs (must include the permit number or address in each picture)
o Each plane of the roof, showing the underlayment installed
o Roof Deck Nailing Pattern & Spacing (including a measuring device or ruler)
o Roof Deck Nails used (including a measuring device or ruler showing size of nails)
o Underlayment Pattern & Spacing (including a measuring device or ruler)
o Drip Edge & Valley Attachment (including a measuring device or ruler)
o Shingles installed, nail pattern and location of nails
Skylights (if applicable)
o Digital photographs showing all installation components, per FL Product Approval
o Digital photographs showing all required flashing, per FL Product Approval
Failure to follow these specific guidelines will result in an affidavit provided by a Florida
Design Professional (Architect or Engineer), certifying FBC code compliance by personal inspection
REVISED: 04-17 Inspection Line: 407.792.6069 or 855.541.2112
D
City of Sanford Building Division
Residential Re -Roof Inspection Policy & Procedures
PERMITTINc REQUIREMENTS — No PLAN R'EVIEw REQUIRED
Phis document (signed) along with an accurate and completed Residential Re -Roof Scope of Work are required
to be submitted as part of your permit application.
The Scope of Work must include all applicable Florida Product Approval numbers for all roof components that
will be installed on the project.
A permit will not be issued without these documents. Copies will be made to post on the job site.
Projects located in the Sanford Historic District will require plan review and approval by the Sanford
Historic. Preservation Board
INSPECTION POLICY & PROCEDURES
A Final Roof Inspection is the only inspection required for Residential (Single Family, Townhouse, Mobile
1-tome, Apartment and/or Condominium) Re -Roof Permits.
The Following is required to be provide on the job site:
Permit Card, posted in a conspicuous and weatherproof location
Completed Residential Re -Roof Scope of Work
Completed and Notarized Inspection Affidavit
All Florida Product Approval and Corresponding Installation Instructions
Product Approval shall match what is on the scope of work)
Digital Photographs (must include the permit number or address in each picture)
o Each plane of the roof, showing the underlayment installed
o Roof Deck Nailing Pattern & Spacing (including a measuring device or ruler)
o Roof Deck Nails used (including a measuring device or ruler showing size of nails)
o Underlayment Pattern & Spacing (including a measuring device or ruler)
o Drip Edge & Valley Attachment (including a measuring device or ruler)
o Shingles installed, nail pattern and location of nails
Skylights (if applicable)
o Digital photographs showing all installation components, per FL Product Approval
o Digital photographs showing all required flashing, per FL Product Approval
Failure to follow these specific guidelines will result in an affidavit provided by a Florida Design
Professional (architect or engineer), certifying. BC code compliance by personal inspection.
CONTRAC'I'OR (OR OWNER/BUILDER) SIGNA'I'UIZ73: DATE: t
D PERMIT #
City of Sanford Building Division
Residential Re -Roof Scope of Work
JOB ADDRESS: 100 OAKRIDGE COURT
STRUCTURE TYPE: (50 SINGLE FAMILY RESIDENCE/TOWNHOUSE Q MOBILE HOME O APARTMENT/CONDOMINIUM
RE -ROOF TYPE: Q REPLACEMENT (TEAR OFF EXISTING ROOF AND REPLACE WITH NEW COMPONENTS)
O RE-COVER (NEW ROOF INSTALLED OVER EXISTING ROOF)
DECK TYPE (PLEASE SPECIFY): 1/2" PLYWOOD
PLEASE NOTE: ONLY 100 SQUARE FEET OF THE EXISTING DECK 1S PERMITTED TO BEREPLACED**
ROOF VENTILATION: (9 OFF -RIDGE O RIDGE O SOFFIT OPOWERED VENT
SKYLIGHTS: OYES ONO IF YES, PLEASE PROVIDE FLORIDA PRODUCT APPROVAL #:
MAIN ROOF AREA
ROOF SLOPE: O LESS THAN 2:12 O 2:12 — 4:12 Q 4:12 OR GREATER
O TURBINES
TYPE OF ROOF MANUFACTURER FLORIDA PRODUCT APPROVAL
SHINGLE CERTAINTEED FL# 5444.1.R10
O METAL FL#
O MODIFIED BITUMEN FL#
O TORCH DOWN FL#
OINSULATED FL#
O TILE FL#
O OTHER: FL#
ROOF EXTENSIONS (PORCHES. PATIOS. ETC.) **IFAPPLICABLE**
ROOF SLOPE: O LESS THAN 2:12 O 2:l 2 — 4:12 O 4:12 OR GREATER
TYPE OF ROOF MANUFACTURER FLORIDA PRODUCT APPROVAL
O SHINGLE FL#
O METAL FL#
O MODIFIED BITUMEN FL#
O TORCH DOWN FL#
OINSULATED FL#
O TILE FL#
O OTHER: FL#
FIRE INSPECTIONS CITY OF SANFORD
407.562.2786 BUILDING & FIRE PREVENTION
BUILDING INSPECTIONS 300 N PARK AVE
855.541.2112 SANFORD FL 32771
DRIVEWAYS -SIDEWALK 407.688.5080
Page 2
Application Number . . . . . 17-00002299 Date 7/27/17
Property Address . . . . . . 100 OAKRIDGE CT
Parcel Number . . . . . . . . 11.20.30.510-0000-1250
Application description . . . ROOFING APPLICATION
Subdivision Name . . . . . . HIDDEN LAKE VILLAS PHASE 5
Property Zoning . . . . . . . MULTIPLE FAMILY
Permit . . . . . . RESIDENTIAL ROOFING PERMIT
Additional desc . .
Phone Access Code 995944
Permit pin number 995944
Required Inspections
Phone Insp
Seq Insp# Code Description Initials Date
1000 111 BL03 FINAL ROOF / /
CITY OF SANFORD BUILDING SERVICES
Residential Re -Roof
Hurricane Mitigation Inspection Affidavit
Permit #:
I, PHYLLIS A. SIMMONS hereby acknowledge that I personally inspected
EkRoof deck nailin and/ r IX Secondary water barrier work
at 100 OAKRIDGE COURT and have determined that the work
Job Site Address)
was done according to the Hurricane Mitigation Retrofit Manual. (based on 553.844 F.S.)
I certify that my statements herein are true and accurate to the best of my belief and that I fully
understand that making any false statements in writing with the intent to mislead a public servant in the
performance of his or her official duty shall constitute a misdemeanor of the second degree pursuant to
Section 837.06 F.S.
Signature of C ntractor 0 Date
PHYLLIS A. SIMMONS CCC1325617
Printed Name of Contractor License #
License Type: General Building Residential q(Roofng Contractor
or any individual certified in accordance with F.S. 468 to make such an inspection.
STATE OF FLORIDA COUNTY OF LAKE
n
Sworn to (or affirmed) and subscribed before me of /-A®ras Pro4uce&(type
204)- , by
PHYLLIS A. SIMMONS who mof identif
ti ) as I en i ication. SEAL)
Sign
re of Notary Public State
of Florida SHIRLEY
CONLEY Print/
Type/Stamp Name of
Notary Public SHIRLEY
CONLtzV MYCOM9t3110N # GG99197 aAdEXPIRES: June302021