408 E Mattie St 04-51 ElectricalCrfY,OF bANt0RD PERMIT APPLICATION tz` _:i
Permit # . Date.
Job Address:
Description of Work: f'X J
Historic District: Zoning: Value of Work: $
Permit Type: Building Electrical Mechanical Plumbing Fire Sprinkler/Alarm Pool _
Electrical: New Service — # of AMPS Addition/Alteration Change of Service Temporary Pole
Mechanical: Residential Non -Residential Replacement New (Duct Layout & Energy Calc. Required)
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:
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel #:
Owners Name & Address:
140 J /= /'Y
Attach Proof of Ownership & Legal Description)
Phone:. 'G % 226 6 /
Contractor Name &/Address: Q O // 307?3 ,$4/to License Number: C -'G.Q of zll cG _
qPhone & Fax: U7 (O 93 by Contact Person: / L lC/-1%}/ ' ' Phone: Bonding
Company: Address:
Mortgage
Lender: Address:
Architect/
Engineer: Phone: Address:
S7
Fax:
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 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 w5tenitanagement districts, state agencies, or federal agencies. Acceptance
of permit is verification that I will notify the owner of the property of the requirement/of Flo d4 Lien Law, FS 71 Signature
of Owner/Agent Print
Owner/Agent's Name Date
Signature
of Notary -State of Florida Date Owner/
Agent is _ Personally Known to Me or Produced
ID APPLICATION
APPROVED BY: Bldg:, Zoning: Initial &
D Special
Conditions: 1'
01 9 IC33 Signature
o ractor/IAgent
J Date
ri
t C tractor/Agent's te A
EN i
U I rJAIfNoia
the'',( r i idai DD ?6a280 Date EXPIRES:
November 1212006 09'
t or rto? Bonded T hruBudget M1btar,, Services Contractor/
Agent is Per& nally Known to Me or So-
Produced ID i"L Utilities:
FD: Initial &
Date) (Initial & Date) (Initial & Date)