1906 W 4 St - P18-004341 REPLACE BATHROOM LINEU
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BUILDING DIVISION
PERMIT APPLICATION
Application No: 18- q __t 4 I Documented
Construction Value: $ 2 , 3 5 0 Job
Address I ri U 6 W q -k Sr Historic District: Yes No Parcel
ID: 26 — lcl- 30 -, So -3 - DO O b- O k o o Residential Z Commercial Type of
Work: New Addition Alteration Repair ® Demo Change of Use Move Description of
Work: cc-sA i coh , rc, i n rePc, 1" r- -tc) r- b o A+ -
o o cM -W P V C, P" m!& Plan Review Contact
Person: N%4/lVe 1 Sim ene9 Title: P/,^,6'IA el Phone: (3c
S) -
96- 36u a Fax: Email: 5S+c ni vn 6 i`ngSe ulie S r. n'tci/%iCa^ PropertyOwner Information
Name A 1
ti ce. Me uct< Phone: qO -7- Z U'y - Y Y . f 4 Street: ) cf0 6
W Resident of property?: City, State Zip:
S m to r cf FL .3 2 -4-? r Contractor Information Name
5 S`'
r F'I v.,6614 Sv w ce S Phone: ( 3 d S0 "- -79 6 - 3 6 a Street: Fax: City,
State Zip:
M.Um, YL . 3 3 1 '9 -4 State License No.: CFG / clZ$ 5 :7 3 Architect/Engineer Information
Name: Phone: Street:
Fax: City,
St, Zip: '`
E-mail: Bonding Company: Mortgage
Lender: Address: 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: 6` 1 Edition (2017) Florida Building Code
NOTICE: In addition to the requirements of this permit, there maybe additional restrictions applicable to this property that maybe 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 ofpermit is verification that I will notify the owner ofthe property ofthe 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.
x l C--)--a4
Sign ture f Owner/Agent Date
Print Owner/Agent's Name
FA: 10/2y/1$
Signature of Notary-Slatdof Florida Date
Owner/Agent is Personally Known to Me or
ProducedJI) T e of ID
Y.ill& lk, -Junior s pin
Tom •-COMISSM I GG1Y O
o! 2 Y/ f6
Signature of Notary -State of Florida Date
Contractor/Agent is Personally Known to Me or
Produced ID _ Type of ID DLP5,5-5yo- $v-o58- TO
Junior JunsorPar pin COWISSION
I GG22939 y ' -
EXPIRES: 6 /18/2022 BELOW IS FOR OFFICE USE ONLY s g. • .... .- , ...
EXPIRES: 6 /t8/2022 fit
Bonded 1Mu AN= Notary „° ' OMM lino Afyon Notary Permits
Required: Building Electrical Mechanical Plumbing Gas Roof Construction
Type: Occupancy Use: Total
Sq Ft of Bldg: Min. Occupancy Load: Flood
Zone: 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:
JJ STATE CERTIFIED CONTRACTOR
COMMERCIAL & RESIDENTIAL
4 CFC 1428673 LICENSED 8 INSURED
WORK ORDER AUTHORIZATION FOR PLUMBING SERVICE
Customer: Insurance Company: _
Phone: (305) 796-3607
11710 SW 180 Street
Miami, FL 33177
5starplumbingservices@gmall.com
6v(&rem S S mce•
Address: 19O ( W 4+` S1— Claim: CID 1 Z10 Icl'-T-4
can rd, t' L 3 Type of Work: CC6* 'r clrw`, Ilne rr. ,ZJ —
Adjuster: Date Of Loss:
I/We hereby authorize 5 STAR PLUMBING SERVICES to perform the following plumbing
service_ CctS 1- ! ro-n c4 cAI l ) PAe. f -ztacii e- 4- -r-v t at my/our property at the above address and with
respect to the items that need to be repair. I/We understand that 5 Star is working for me/us and not for the Insurance Company,
adjuster and/or agent. 5 Star Plumbing Services shall bill all charges and/or costs directly to me/us and I/we are responsible for the
entire bill when services are rendered. If applicable and provided that I/we have valid effective insurance coverage for all or part of the
services to be performed by 5 Star Plumbing Services, solely as a courtesy, 5 Star Plumbing Service will bill my/our Insurance
Company and request payment for insurance covered services. 1/We am/are responsible for any and all charges not covered by
my/our Insurance company. If in any event my/our Insurance Company remits any payment directly to me/us for services billed by 5
Star Plumbing Services, I/We hereby agree to pay 5 Star Plumbing Services immediately. I/We understand that in the event that
payment of my/our deductible is applicable is to be made today.
DIRECTION TO PAY: I/We hereby direct and authorize my/our Insurance Company (as noted above) to pay and remit directly to 5 Star
Plumbing Services any monies which are now payable or which may became payable to me/us by my/our insurance policy in respect
of the loss sustained under the claim noted above; in connection with services provided by 5 Star Plumbing Service, and to name 5 Star
Plumbing Services on any insurance drafts paying for services provided by 5 Star Plumbing Services applicable to this loss. I/We
authorize 5 Star Plumbing to contact my Insurance Company to inquire about its payment and authorize my/our Insurance Company to
disclose any and all necessary information to settle 5 Star Plumbing Services' payment.
Services will be perform according to the Final specification and detailed Estimate submitted by 5 Star Plumbing Services to my/our
Insurance Company,and for the total amount allow by my/our Insurance Company.
I[We authorize my/our mortgage company IVZ4 Loan# trA to
release any information pertaining to this loss and any and all draft issued by my/our Insurance Company with named 5 Star
Plumbing Services as a payee for services performed by 5 Star Plumbing Services. Also I/We authorize my/our Mortgage
Company to release any and all draft issued by my/our Insurance Company for service performed and completed by to 5 Star
Plumbing Services directly to 5 Star Plumbing Services.
The liability of 5 Star Plumbing Services is expressly limited to the total amount of the services authorized herein and in no event shall
5 Star Plumbing Services, its agents, assigns, successors, predecessors, heirs, executors, representatives, administrators and
employees, be liable for consequential damages of any kind. I/we fully understand and agree that 5 Star Plumbing Services is not an
agent of the Insurance Company, and/or claims adjuster and/or Insurance Agent, and I/We waive all rights to claim 5 Star Plumbing
Services as an agent of either.
IIWe understand that Uwe have the right to cancel this contract within three (3) days of signing this forms, However in the event that
5 Star Plumbing Services begin to perform the services within the three (3) days of signing I/We waive that right to cancel. In the event
that legal or collection agency proceedings must be instituted to recover any amount due, 5 Star Plumbing Services shall be entitled to
recover the cost of collections, including, collection agencies, attorneys fee and court costs, plus a finance charge of 1.5% per month
applicable to all amounts due. UNDERSIGNED FURTHER ACKNOWLEDGES RECEIPT OF THE NOTICE PURSUANT TO
FLORIDA STATUTE 713.015.
Deductible paid with: %i / I I Date: k) A -
Customer Signature: / \ J 2, 356 Date: !/ o — a
Customer Signature: Date: