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1200 S Park Ave - BR18-002763 - ShedCITY OF E(; EIVIficationNo:. PERMIT APPLICATIONSk4FORqJUN202018BUILDINGDIVISION BY, 14 , 0 Documented Construction Value• 01S —5 s "1/ Address: GOO L AV'(— :5q:2Ve:MD R_ 3)774 Historic District: Yes;l No Parcel ID: Residential Commercial Type of Work: New Addition Alteration Repair Demo Change of Use Move J) dscription of Work:` I -IRA 4% X 12 qL4"5olf Plan Review Contact Person: Phone: Fax: Email: Title: Property Owner Information Name 11 1?i Phone:_7 Street: L C D _S i `L Resident of property? City, State Zip: c?i ` (,, 3a-1 7 ) Contractor Information Name Phone: Street: City, State Zip: Name: Street: City, St, Zip: Bonding Company: Address: Fax: State License No.: Architect/ Engineer 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. 1 understand that a separate permit must be secured for electrical work, plumbing, signs, wells, pools, furnaces, boilers, heaters, tanks, and air conditioners, etc. Revised: June, 2018 Permit Application FBC 105.3 Shall be inscribed with the date of application and the code in effect as of that date: Vh Edition (2017) Florida Building Code' NOTICE: In addition to the requirements ofthis permit, there may be additiotal'restrictionsapplicable to this property that maybe found iti; he public records of this county, and there may be additional permits 'required from other governmental entities such as water management disInets, 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. Print Owner/Agent's Name i n ., / / Signature ofContractor/Agent Date Print Contractor/Agent's Name Sig ature of Notary-ttalltmDawa NOT V B to " Signature of Notary -State of Florida Date ARY STATE OF FLORIDA Caar* GG2217377 Owner/Agent is T ersonaPUy Kno1 Me or Contractor/Agent is Personally Known to Me or Produced ID V Type of ID Ft- D (- Produced ID Type of ID BELOW IS FOR OFFICE USE ONLY Permits Required: Building Electrical Mechanical Plumbing Gas Roof Construction Type: Occupancy Use: Flood Zone: Total Sq Ft of Bldg: Min. Occupancy Load: of Stories: New Construction: Electric - # of Amps Plumbing - # of Fixtures Fire Sprinkler Permit: Yes No # of Heads APPROVALS: ZONING: ENGINEERING: COMMENTS: UTILITIES: FIRE: Fire Alarm Permit: Yes No WASTE WATER: BUILDING: Revised: June, 2018 Permit Application 0 CERTIFICATE OF APPROPRIATENESS HISTORIC PRESERVATION BOARD CITY OF SANFORD 300 S. Park Avenue Sanford, Florida 32771 407.688.5145 • www.sanfordflgov/HP/HP THIS DOCUMENT MUST BE POSTED AT ALL TIMES UNTIL PROJECT IS COMPLETED. ISSUED TO: DATE ISSUED: Joseph Pietzyk June 14, 2018 for 1200 S. Park Avenue DATE EXPIRES: Sanford, FL 32771 December 15, 2018 BP#18-2699 Approved to install a 8x12 wooden shed with pitched shingled roof. Accessory storage structures shall not exceed 100 sq. ft., must be a minimum distance of 10' from the main structure and shall not exceed the height of the main.structure. Approved to paint same colors as main structure SW Classical White and Westchester Gray. At time of permitting all setback requirements must be met. Russ Gibson, Director of Planning & Development Department Please be advised it is the owner and/or agent's responsibility to notify staff of any potential changes from the approved COA that arise and obtain approval prior to commencing the changes. This Certificate of Appropriateness does not constitute final development approval. The applicant is responsible. for obtaining all necessary permits and approvals from applicable departments before initiating development. IS A BUILDING PERMIT REQUIRED FOR THE IVITY LISTED ABOVE? DYES D NO Building Depar ent Re resentative It CITY OF S,kiI4FORD Building & Fire Prevention Division SHED / GAZEBO PERMIT GUIDELINES FIRE DEPARTMENT All permit application packages must be complete prior to acceptance. You must check each box to the left or indicate n/a on this submittal. A complete application package shall include the following: O Building Permit Application completed, signed and notarized. Application must include correct address and complete parcel I.D. number. O Copy of a contract, signed by the contractor and the property owner, indicating the documented construction value of the project. O Copy of applicable contractor's license issued by the State of Florida (if contractor is applicant). O A site specific notarized power of attorney shall be required from the licensed contractor if he/she appoints an employee of his/her company to sign the permit application as the contractor. O Certificate of insurance indicating worker's compensation insurance coverage and naming the City of Sanford as certificate holder, or a copy of a worker's compensation exemption issued by the State of Florida (must be submitted with each application if contractor is the applicant). O Owner Builder Statement / Affidavit (if owner is applicant). D Two (2) site plans indicating proposed location and distances to property line(s). Shed 10'x 12'or less: Signed and notarized Shed Affidavit O Gazebo 10' x 12' or less: Two (2) copies of Construction plans (legibly hand -drawn or drafted) indicating in detail how the structure will be built. All framing members and sizes as well as framing connectors must be specified. Foundation detail — how will gazebo be secured to the foundation O Shed or Gazebo greater than 10' x 12': Two (2) sets signed and sealed engineered drawings. Wind design data required on drawings per FBC 1603.1.4 to meet 129 mph ultimate design wind speed for risk category I buildings. Completed and signed Statewide Product Approval Specification Form. Two (2) copies of manufacturer's installation instructions. Florida State Department of Community Affairs Approved Building. These guidelines were compiled to assist the applicant in preparing a Shed / Gazebo permit application and may not be complete. The applicant is required to meet all City ofSanford, state, andfederal code requirements. Effective: August 1, 2017 OWNER BUILDER STATEMENT/AFFIDAVIT Altamonte Springs, Casselberry, Lake Mary, Longwood, Oviedo, Sanford, Seminole County, Winter Springs Florida Statutes are quoted here in part for your information to indicate the authority for exemptions for homeowners from qualifying as contractors and to express any applicable restrictions and responsibilities. OWNERS MUST PERSONALLY APPEAR AT THE BUILDING DIVISION TO SIGN THIS DOCUMENT BY SIGNING THIS STATEMENT, I ATTEST THAT: (Initial to the left of each statement) I understand that state law requires construction to be done by a licensed contractor and have applied for an owner -builder permit under an exemption from the law. The exemption specifies that 1, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. I understand that, as an owner -builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that a contractor is required by law to be licensed in Florida and to list his or her license numbers on all permit and contracts. I understand that I may build or improve a one -family or two-family residence or a farm outbuilding. I may_ also build or improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my own use or occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or ]eased within in I year after the construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates this exemption. I understand that, as the owner -builder, I must provide direct, onsite supervision of the construction. I understand that I may not hire an unlicensed individual person to act as my contractor or to supervise persons working on my building or residence. It is my responsibility to ensure that the persons whom I employ have the licenses required by law and by city ordinance. I understand that it is a frequent practice of unlicensed persons to have the property owner obtain an owner -builder permit that erroneously implies that the property owner is providing his or her own labor and materials. 1, as an owner -builder, may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an owner - builder and am aware of the limits of my insurance coverage for injuries to workers on my property. I understand that I may not delegate the responsibility for supervising work to a licensed contractor who is not licensed to perform the work being done. Any person working on my building who Is not licensed must work under my direct supervision and must be employed by me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers' compensation for the employee. I understand that my failure to follow these laws may subject me to serious financial risk. Rev. 9.14.2009 I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern owner -builders as well as employers. I also understand that the construction must comply with all applicable laws, ordinances, building codes, and zoning regulations. I am of aware of construction practices and 1 have access to the Florida Building Codes. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States Small Business Administration, the Florida Department of Financial Services, and the Florida Department of Revenue. I also understand that I may contact the Florida Construction Industry Licensing Board at 1-850-487-1395 or at www.myflorida.com/dbpr/pro/cilb/ for more information about licensed contractors. I am aware of, and consent to, an owner -builder building permit applied for in my name and understand that 1 am the party legally and financially responsible for the proposed construction activity at the address listed below. I agree to notify the building department immediately of any additions, deletions, or changes to any of the information that I have provided on this disclosure or in the permit application package. Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the Construction Industry Licensing Board, the Department of Business and Professional Regulation and the building department may be unable to assist you with any financial loss that you sustain as a result of a complaint. Your only remedy against an unlicensed contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner -builder permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is property licensed and the status of the contractor's workers' compensation coverage. Pro"perty v and capable of performing conditions specified above. 1 ' requested construct; Form of Identification Must be Photo ID) r , do hereby state that I am qualified i involved with the permit application filed and agree to the ate A violation of this exemption is a misdemeanor of the first degree punishable by a term of imprisonment not exceeding 1 year and a $1,000.00 fine in addition to any civil penalties. In addition, the local permitting jurisdiction shall withhold final approval, revoke the permit, or pursue any action or remedy for unlicensed activity against the owner and any person performing work that requires licensure under the permit issued. Rev. 9.14.2009 WK OF LEESBURG 2118 US-441 LEESBURG, FL 34748ralPHONE: 352-326-8089 AU)IORIZED AGENT OF WEATHER KING BUILDINGS (ADAM,MONICA) SELECT ONE: 0 CASH SALE O RENT TO OWN I Shop: BUSHNELL, FL SALESMAN: Adam Please Fill In Date DATE: I 06N4/18 Choose Building Sale Type New -Order Sale Please Select One Of The Building Types O EMUT I RTO HOLDER: SaG ENTERPRISES. LLC Painted O Treated O urethane O Z Metal O Econ o E Barn SIDING COLORS: TRIM COLORS: ROOF COLORS: SMUT Painted: Dark Gray Painted: Almond IHF*eTH-s7nNL S COTTAGE SHED GARAGE LOFTED BARN Lofted Barn Cabin Side Lofted Bam Side Utility 8' Walls 8xl 27 Utility 8' Walls Lofted Bam Garage I Garden Utility Side LBC Back Yard Way Deluxe LBC Deluxe C I I T IvrT rtvna uwasssr s svn SELECT YOUR PAYMENT DUE DATE: O 15T O STH O 10TH O 15TH CODE COST 0 0.00 o 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 ROOF 0.00 PURCHASER NAME Joseph P Pietzyk CO/RENTER ROOF $0.00 CO -Cell: c0•Employer. CO-Wk Ph: TOTAL $0.00 MAILING ADDRESS DELIVERY ADDRESS 1200 S Park Ave 1200 S Park Ave City: Sanford State: I Florida Zip:32771 County: Seminole Exempt City City: ISanford state: I Florida ZIP:32771 County: Seminole HOME PHONE: (407) 222-8064 Own / Rent: Land? Own Land WORK PHONE: Landlords Phone: rNELL PHONE- FAX TO CORPORATE OFFICE AT DRIVER TO PICK-UP REMAINING "BALANCE" I MAKE ALL CHECKS PAYABLE TO ESTIMATED DELIVERY DATE: 10 TO 21 WORKING DAYS FROM PURCHASE DATE. "'WEATHER KING PORTABLE BUILDINGS**' OPTION DRAWING: SHOW STANDARD "DOORISI- THEN PLACE YOUR "OPTIONS" PENCIL in W ERE a give Measurementsfrom END or.t= of@.2Q. to vi6CE options DOORS FACING DIRECTIONS Weather King Portable Buildings and its agents are NOT responsible for permits, setbacks, restrictions. or covenants. PLEASE contact your local codes department or Homeowners Association. It is up to the customer to decide whether around conditions are suitable for delivery. 'Weather King Portable_agkinggs is NOT responsible for ar or driveway damage. Free delivery and set up includes, ONE TRIP, additional trips may incur CHARGES to the customer. Weather King DOES NOT ANCHOR BUILDINGS. First 50 miles Free Delivery From Lot Thereafter $3.00 Per Mile. iammo Mew %,vmvs iwino yr omuc Controlling Terms and Conditions. These terms and conditions of sale of Consolidated Industries, LLC, d/b/a Weather King Sheds('Seller) and any attachments hereto take precedence over any additional or different terms and conditions, if any, of the purchaser identified on the first page of this order (`Purchaser'), to which notice of objection is hereby given. Seller's acceptance of this order is expressly conditioned upon Purchaser's acceptance of these terms and conditions. These terms and conditions, together with any other written agreement directly related to this transaction, will constitute the entire agreement between the parties with respect to the portable building(s) sold hereunder. Modification or Relocation of Building. Any building that is currently or is to be out on a rent to own contract is NOT to be altered or modified in any way until the building is paid in full, nor under any circumstance can it be relocated. You must first contact the rental company to schedule a move. Any building that Is moved to a different location without the consent ofthe rent to own contract holder will be considered stolen and the culprit WILL be prosecuted to the full extent of the law. Not for Re -Sale or Human Occupancy: Release & Indemnification. Purchaser acknowledges that the portable building(s) sold hereunder may not be re -sold and are NOT DESIGNED OR SUITABLE FOR HUMAN OCCUPANCY OR HABITATION. Accordingly, Purchaser hereby releases and forever discharges Seller, and will indemnify, defend and hold Seller harmless, to the maximum extent permitted by law, from and against any claims, liability, expenses, regulatory or administrative actions, injunctions, damages, or cost of any kind, including without limitation reasonable attorney fees, arising from or in connection with (1) the purchaser's sale or transfer of any portable building(s) to any other person or entity, (ii) the human occupancy or portable building(s) sold hereunder, (iii) the modification of any portable building(s) in any manner that results in the square footage of any portable buildings exceeding 400 square feet, or (iv) the placement of any such portable building(s) within three feet of any other structure or property line. Compliance with Laws. Purchaser hereby represents and warrants to Seller that Purchaser has complied, and Purchaser's use and placement of the portable building(s) sold hereunder will comply, with all federal, state and local laws and regulations, including without limitation local zoning codes, setbacks, covenants,permits and land use regulations, Seller does not represent that the portable building(s) sold hereunder are approved for use or placement in any specific location Purchaser is responsible for determining whether the portable building(s) may be used or placed in any specific location or for any particular purpose, and purchasers inability to use or place the portable building(s) sold hereunder in any specific location or manner. Risk Of Loss & Delivery Charges & Release Title and all risk of loss will pass to purchaser upon delivery. Seller or Seller's design will attempt to deliver the portable building(s) sold hereunder one time at (1) no additional charge for deliveries within 50 odometer miles of the location of purchase, ii) at an additional, one way charge of $3.00 per mile for every additional odometer mile beyond the first 50. Delivery means transport of the portable building(s) to purchasers specified destination and release of portable building(s) on to a reasonably level, suitable service accessible by truck with adequate clearance for the portable building(s), and leveling the portable building(s) with treated wood blocks or suitable concrete blocks to be provided by Purchaser. Unless otherwise confirmed in writing by Seller, adequate clearance requires, at a minimum (1) three feet of clearance from any other structure or any property line on any side of portable building(s) as they will be delivered,and (II) overhead clearance equal to the height of the portable building(s) plus four feet. Seller or Seller's design, in it's or their sole discretion will determine whether there is adequate access and clearance to Purchasers proposed delivery sight and whether the surface is sufficiently level and suitable to support the portable building(s) sold here- under. If seller determines for any reason that the delivery cannot be completed, purchaser and seller will arrange for a second delivery attempt at an additional, one way charge of $3.00 per mile for every odometer mile from the location of purchase. Purchaser releases and forever discharges Seller from any liability resulting from any damage to Purchasers property incurred during delivery. Attempt, including without limitation damage to damages to person or property, loss of use, loss of time, inconvenience, equipment rental, loss of earnings or profits or any commercial loss relating to yards or driveways. Limitation of liability, Seller will not be Fable for punitive, incidental or consequential Purchasers order. The remedies of Purchaser as set forth herein are exclusive. The liability of Seller with respect to the sale and delivery of any portable building(s) under this order, whether in contract, in tort, under any warranty or otherwise, will not exceed the difference between the price of the portable building(s) as specified on the first page of this order and the value of the portable building(s) as delivered by seller. Additionally, Seller will not be liable for any loss or damage of any kind arising from delay or inability to delivery beyond Sellers reasonable control, or from improper maintenance, alteration or misuse of the portable building(s) Cancellation. Partial Refund/Restocking Fee. Orders for standard portable building(s) may be canceled by purchaser at any time before delivery. If Purchaser cancels such an order, Purchaser will pay to seller a restocking fee equal to 15% of the purchase price shown on the first page of this order. The *Restocking Fees'). Such restocking fee will (1) be retained by seller if purchaser has paid all of the purchase price for a portion of the purchase price equaling or exceeding 15% of the purchase price at the time of cancellation, provided that Seller will refund to Purchaser all amounts in excess of the Restocking Fee, or (II) be immediately due and payable by purchaser to seller at the time of cancellation if Purchaser has paid none of the purchase price or a portion of the purchase price equaling less than 15% of the purchase price, provided that Seller may apply against such Restocking fee any amounts Then -paid by Purchaser Orders for custom build or custom painted portable building(s) may not be canceled except with prior written consent of the seller, which consent may withhold for any reason or no reason. Consent to Jurisdiction. If Purchaser is a governmental entity or Indian Nation, PURCAHSER HEREBY EXPRESSLY WAIVES ITS DEFENSE OF SOVERIGN OR OTHER IMMUNITY IN THE EVENT OF A DISPUTE BETWEEN PURCHASER AND SELLER REGARDING THIS ORDER. Regardless of whether Purchaser is a governmental entity or Indian Nation, PURCHASER EXPRESSLY ACQUIESCES TO THE JURISDICTION AND VENUE OF THE UNTIED STATES FEDERAL AND STATE COURTS. Warranties And Disclaimer of Warranties NOT INCLUDING REPOS AND OR DISCOUNTED BUILDNG(S) Seller warrants to original user of the portable building(s), provided the building(s) remains at original delivered location that the portable building(s) sold hereunder will be warranted against the rot, and/or decay of treated materials for the life of the building(s), against termite infestation of all treated materials for 20 years, and defects in material or craftsmanship within 3 years of the original delivery date not including damaged caused by external sources such as wind damage to shingles. Sellers sole obligation in purchasers sole remedy under this Warranty is replacement of the portable building(s), or at Sellers option, the defective portion thereof that Seller finds is defective in material or craftsmanship within the warranty time period. Any replacement performed under this Warranty will be performed by Seller or Sellers design. The above warranty will be null and void in the event that the portable building(s) are altered by purchaser, or have been, in Sellers sole judgment, subject to negligence, improper maintenance or misuse or moved from original delivered location. Sellers liability is further limited as provided by the Limitation of Liability section of these terms and conditions, SELLER DISCLAIMS ALL OTHER WARRANTIES, INCLUDING WITHOUT LIMITATION THE IMPLIED WARRANTIES OF MERCHANTABILTY AND FITNESS FOR A PARTICULAR PURPOSE). Miscellaneous. This order and these terms and conditions will be construed under state law without regard to the choice of law principles thereof. No waiver of any breech of any provision of this contract will constitute a waiver of any other breach of such provision If one or more of these terms and Condition is for any reason beheld to be invalid, illegal or unenforceable in any respect, such invalidity, illegality, or unenforceability will not effect any other term or condition and such invalid, illegal, or unenforceable provisions will be modified to the minimum extent necessary to render such provisions valid, legal and enforceable. Printed Name: Signature: s1 Weather King Portable Buildings Delivery and Space Requirements Weather King Portable Buildings provides delivery of the buildings we sell. Delivery will go smoothly when proper arrangements are made in advance. Free delivery and set-up only includes one trip to the specified delivery location located within 50 odometer miles from the nearest Weather King Sales Center. Set-up includes leveling the portable building with treated wood blocks provided by the delivery driver; or suitable 4" flat solid concrete blocks available at the site and provided by the Customer. Buildings are set on skids at grade with 'treated wood shims' used to level the building. Drivers will not set a building above 6" from ground level without an extra cost. Wood or 4"flat solid concrete blocks above 6" in height may require extra time and material which the customer must agree to pay directly to the driver at the time of delivery. The driver will level the building when it is delivered initially. If the buildings settle after being loaded with belongings this is not a warranty issue. If the driver is needed to go back to re level that will be the responsibility of the customer. Any State or local requirement for ground ties or anchoring is the responsibility of the customer. There must be enough space for not only the building but also the truck and the trailer. There are some things to consider for the delivery of your building. The truck and trailer that will be delivering your building may exceed 75' in length and when loaded with your building may exceed 15.6' in height. Low ranch gates may cause issues for the driver when entering the property. Low power lines and telephone line must be considered for the delivery of the building also. Adequate clearances require a minimum of four feet from any other structure or property line on any side of the portable building, and overhead clearance equal to the height of the portable building plus five If another trip is necessary to make delivery, the customer will bear the entire cost of the subsequent delivery negotiated between customer and Transportation Company. If the delivery is more than 50 odometer miles from the closest Weather King Sales Center, the customer hereby acknowledges responsibility to pay the delivery driver $3.00 per mile (one way) for ever additional odometer mile beyond the first 50 miles. Customer agrees to pay any additional delivery charge prior to the driver unloading the building. Delivery personnel are not responsible for the trimming of trees, clearing of brush or stumps, or the removal of fences & gates or any other obstructions at the delivery site. Please use conservative judgment when considering ditches and/or tight access routes turns on rural access roads. Customer Name: (type or print) Sale Date: V /Icy/ / Sales Lot: / PG 6u,r-i Type of Building: PS UTX Building ID: I understand the above deliver requirements and have determined that there is adequate space for the de ' of th in purchased. 11 WEATHER KING Joe Pietzyk a 06/ 14/2018 Dat 52 9 Dealer Signature White Single c WindowDoor White t Window 12' Barn: Finishes: Model: Side Utility Roof: Shingles - Hearthstone Shingles Size: S x 12 Siding: Paint - Dark Gray Trim: Paint - Almond 00 Options White 2x3 Window Single Barn Door 0 ScanORcode to preview bW&V. https://goo.gIIny FOz Count 2 1 ONSOLIDATED INDUSTRIES O. BOX 108 AR1S, TN 38242 CREDIT CARD AUTHORIZATION FORM Transaction w,iUteotstie run anlessAihis sheetlisiaccompani 'd,by, a;;work.:o.d'er for new sales__ _ _ I =Josepli'.P k. Authorize Consolidated Industries to charge my credit card. Customer Name For services rendered not to exceed the amount shown. r1[T4ZTnM1F12 111VPn1DMAT1nN AC NAMF. APPFARR ON CARD Date - - 01, :4i/.18,: , .. Customer Name JosephP: "Pietzyk Billing Address 37,6,Cadd'ie Dr: . c; Debary state FI"O ida.- ' z; .code 32713. Phone Numbers Home: 407 222,-806*'. 1 Work:"; CARD CVV2 N EXPIRATION DATE NAME ON CARD - AS IT APPEARS ON Last 3 digits of the code on the back of the card. FAX OR EMAIL TO: CONSOLIDATED INDUSTRIES P.O. BOX 108 PARIS, TN 38242 1-866-977-6440 (OFFICE) 888-695-7616 (FAX) orders@consolidated buildings. com(EMAI L) Please Att h, .A C-,'— f `'Dri efs Licer s_% oniB Ba'ck`of Credit Cara. ThankpYi 31Di , it N e11# 397 4; W , L.l1eater MustTFi11 In Data' ? OLD BY: R.z•,;AIIOIiII'Gai`' OT: Lreesbu;g ALESMAN: Bla-mul rs.' UILDING NUMBER: If Know, if not # of buildings purchased) OTES: