HomeMy WebLinkAbout15-16008 �
CITY OF ZEPHYRHILLS
5335-8TH STREET
(813)780-0020 1 08
• � BUILDING PERMIT
PERMIT INFORMATION LOCATION INFORMATION
Permit Number: 16008 Address: 38444 COTTONWOOD PL
Permit Type: MECHANICAL ZEPHYRHILLS, FL.
Class of Work: A/C CHANGEOUT Township: Range: Book:
� Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
� Square Feet: Subdivision: DRIFTWOOD
Est. Value: Parcel Number: 02-26-21-0210-00000-1080
Improv. Cost: 3,700.00 OWNER INFORMATION
Date Issued: 2/19/2015 Name: BLACK, SHIRLEY
Total Fees: 55.00 Address: 38444 COTTONWOOD PL
Amount Paid: 55.00 ZEPHYRHILLS FL 33542
Date Paid: 2/19/2015 Phone: 352-807-8406
Work Desc: A/C CHANGE OUT 2.5 TON HEAT PUMP
CONTRACTOR S APPLICATION FEES
AIR TECH SERVI E F PAS O INC CHANGE UT 55.00
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Ins ections Re red
DUCTS INSTALLED
DUCTSINSULA D
FINAL �
� REINSPECTION FEES: Reinspection fees will comply with Florida Statute 553.80 (2)(c) when extra inspection
trips are necessary due to any one of the following reasons: a)wrong address b) condemned work resultin
9
from faulty construction c) repairs or corrections not made when inspections called d)work not ready for
inspection when called e) permit not posted on job site f) plans not at job site g) work not accessible.
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, state agencies or federal agencies.
"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."
Complete Plans,Specifications Must Accompany Application.All work shall be performed in accordance with
City Codes and Ordinances. NO OCCUPANCY BEFO C.O.
CONT CTOR SIGNATURE PERMIT OFFI R
RMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021
Building Department
Date Received Phone Contact for Permitting -- '�
Owner's Name J�11Y'12 �I�ckwe l Owner Phone Number C.Q.QQ �3�.— �b —�S �U
Owner's Address y� �.G o L� Owner Phone Number �l�a` �� ��O
Fee Simple Titleholder Name Owner Phone Number
Fee Simple Titleholder Address
JOB ADDRESS 3 S�+y�[ ��Y\ OO d �—� LOT# �
SUBDIVISION 1����1 WW� M�� PARCEL ID#
I (OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED � NEW CONSTR 8 ADD/ALT � SIGN Q Q DEMOLISH
INSTALL REPAIR
PROPOSED USE Q SFR Q COMM � OTHER
TYPE OF CONSTRUCTION Q BLOCK Q FRAME Q STEEL Q
DESCRIPTION OF WORK A �� C�.,If��'l •Q �(,t�
BUILDING SIZE SQ FOOTAGEL� HEIGHT
QBUILDING $ VALUATION OF TOTAL CONSTRUCTION
QELECTRICAL $ AMP SERVICE Q PROGRESS ENERGY Q W.R.E.C.
OPLUMBING $ �
-��+ NIECHANICAL $ .�„� VALUATION OF MECHANICAL INSTALLATION � J �v�
� �
QGAS Q ROOFING Q SPECIALTY Q OTHER S�`
��
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA QYES NO
BUILDER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N
Address License#
ELECTRICIAId COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N
Address License#
PLUMBER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N
Address License#
y
� MECHANICAL � i COMPANY 1�T K �V\C.ri �� G�I�SCO
' SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N
Address p•�•'IUj6X lav Z���� �l.L � 3 S��{ License# �AC t��"rJ���
OTHER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N
I Address Ucense#
` RESIDENTIAL Attach(2)Plot Plans;(2)sets of Building Plans;(1)set of Energy Forms;R-O-W Permit for new construction,
� Minimum ten(10)working days after submittal date. Required onsite,Construction Plans,Stormwater Plans w/Silt Fence.installed,
' Sanitary Facllities 8�1 dumpster;Site Work Permit for subdivisionsflarge projects �
COMMERCIAL Attach(3)complete sets of Building Plans plus a Life Safety Page;(1)set of Energy Forms.R-O-W Permit for new wnstruction.
Minimum ten(10)working days after submittal date. Requ(red onsite,Construction Plans,Stormwater Plans w/Silt Fence installed,
Sanitary Facilities&1 dumpster.Site Work Permit for all new proJects.All commercial requirements must meet compliance
SIGN PERMIT Attach(2)sets of Engineered Plans.
""'PROPERTY SURVEY required for all NEW construction.
Directions:
Fill out application completely.
Owner&Contractor sign back of application,notarized
If over 52500,a Notice of Commencement is required. (A/C upgrades over 57500)
"' Agent(for the contractor)or Power of Attomey(for the owner)would be someone with notarized letter from owner authorizing same
OVER THE COUNTER PERMI7TING��, ='- (Front of Application Qnly)
Reroofs if shingles Seuvers_;,;-, Senrice Up"'g'rades A/C � �Fences(Plot/Survey/Footage)
Driveways-Not over Counter if on public roadways..needs ROW
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to"deed; restfictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any
applicable deed restrictions.
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If.the owner has hired a contractor or
contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the
contractor is not licensed as required by law, both the owner and contractor may be cited for a misdemeanor violation
under state law. If the owner or intended contractor are uncertain as to inrhat licensing requirements may apply for the
intended work, they are advised to contact the Pasco County Building Inspection Division—Licensing Section at 727-847- I
8009. Furthermore, if the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign I
portions of the "contractor Block" of this application for which they will be responsible. tf you, as the owner sign as the
contractor, that may be an indication that he is not properly licensed and is not entitled to permitting privileges in Pasco
County.
TRANSPORTATION IMPACTIUTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings, change of
use in existing buildings, or expansion of existing buildings, as specified in Pasco County Ordinance number 89-07 and
90-07, as amended. The undersigned also understands, that such fees, as may be due; will be identified at the time of
permitting. It is further understood that Transportation Impact Fees and Resource Recovery Fees must be paid prior to ,
receiving a "certificate of occupancy" or final power release. If the project does not involve a certificate of occupancy or
final power release, the fees must be paid prior to permit issuance. Furthermore, if Pasco County Water/Sewer Impact
fees are due, they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW(Chapter 713, Florida Statutes, as amended): If valuation of work is $2,500.00 or more, I
certify that I, the applicant, have been provided with a copy of the "Florida Construction Lien Law—Homeowner's
Protection Guide" prepared by the Florida Department of Agriculture and Consumer Affairs. If the applicant is someone
other than the"owner", I certify that I have obtained a copy of the above described document and promise in good faith to
deliver it to the"owner"prior to commencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT: I certify that all the information in this application is accurate and that all work
will be done in compliance with all applicable laws regulating construction, zoning and land development. Application is
hereby made to obtain a permit to do work and installation as indicated. I certify that no work or installation has
commenced prior to issuance of a permit and that all work will be performed to meet standards of all laws regulating
construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. I also
certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is
my responsibility to identify what actions I must take to be in compliance. Such agencies include but are not limited to:
- Department of Environmental Pratection-Cypress Bayheads, Wetland Areas and Environmentally Sensitive
Lands, Water/Wastewater Treatment.
- Southwest Florida Water Management District-Wells, Cypress Bayheads, Wetland Areas, Altering
Watercourses.
- Army Corps of Engineers-Seawalls, Docks,,Navigable Watenrvays.
- Department of Health � Rehabilitative Services/Environmental Health Unit-Wells, Wastewater Treatment,
Septic Tanks.
- US Environmental Protection Agency-Asbestos abatement.
- Federal Aviation Authority-Runways.
I understand that the-following restrictions apply to the use of fill:� ,
- Use of fill is not allowed in Flood Zone"V"unless expressly permitted.
- If the fill material is to be used in Flood Zone "A", it is understood that a drainage plan addressing a
°compensating volume" will be submitted at time of permitting which is prepared by a professional engineer
licensed by the State of Florida. �
- If the fill material is to be used in Flood Zone "A" in connection with a permitted building using stem wall
construction, I certify that fill will be used only to fill the area within the stem wall.
- If fill material is to be used in any area, I certify that use of such fill will not adversely affect adjacent
properties. If use of fill is found to adversely affect adjacent properties, the owner may be cited for violating
the conditions of the building permit issued under the attached permit application, for lots less than one (1)
acre which are elevated by fill, an engineered drainage plan is required.
If I am the AGENT FOR THE OWNER, I promise in good faith to inform the owner of the permitting conditions set forth in
this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical work,
plumbing, signs, wells, pools, air conditioning, gas, or other installations not specifically included in the application. A
permit issued shall be construed to be a license to proceed with the work and not as authority to:violate, cancel, alter, or
set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter
requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid
unless the work authorized by such permit is commenced within six months of permit issuance, o� if work authorized by
the permit is suspended or abandoned for a period of six(6) months after the time the work is commenced. An extension
may be requested, in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate
justifiable cause for the extension. If work ceases for ninety(90)consecutive days, the job is considered abandoned.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
- -Pr��I�l7 T�l���E�'R�lit�t�7�4 i�Ciro�iv i�-�d���F:-�iR�R�R�:-9F'�R•2C.D-�edT'�l+:�-3' TA?9d F�NAl�l�I�IG,-��M$llLT --
^ WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTI O C MMENCEMENT.
FLORIDA JURAT(F.S.117.03) �
, -
OWNER OR AGENT CONTRACTOR
Subscribed and swom to(or affirmed)before me thfs Subscribed and swom to(or a rf ied)before me this
v
by
Who islare personally known to me or has/have produced Who ts/are sop Ily own to me or has/have produced
as IdenUfication. as identi6cation.
Notary Publlc �� Notary Public
,,��,
��'• JACQUELINE
Commisslon No. Com ssf No. �, �.�: GES
;; .c;;g� Expires December 12 222
� VF�
Name of Notary typed,printed or stamped Name of Notary �""s'°°"�800�esaoie
I
- � . Page No. of. Pages
� ����d���
� _ ��� ���[ � ��[������� ��ld• P.O.80X 112Q
Zephyrhilis,PI�33539
' i��' 1°I�atin� ar�� �/� �ontr�ct�r s�3-779-7508
FL State Lic.#CAG1815498 '
FROPOSAL SUBMITTED T{?: �^ �1`( � �����! QA7E: �y �� ��
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STREET '�Z,l3 � -�'.. �Bi3�'Y-J�` F 4.�{.-� ['HONE: `?�� ��`.'� '"' V��S.�
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CIIY,STATE and ZIP CODE ^
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We hereby submit specifications and estimates far: _
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��L Ptt��roSe hereby to furnish material and labor-complete in accordance with above specifications, for the sum
' dollars{$ _ 1 .
Payment to be made as follows:
% at commencement, °lo at the completian of the job.
All material is guaranteed to be as specified.All work to be completed in a workmanlike �,� �
ma�ner aecording to standard pract3ces. Any alteration or deviation from above Authoriz c) ��2��"�:�f____1'��__a��G`',�.
speciflcations involving extra cosfs,will be executed only upan writien orders,and wiN l ,�:�
become an extra charge over and above the estimate.All agreements contingent upon ��9nature:
strikes,accidents or delays beyond our control. Owner to carry fire,tornado,and other , '
necessary insvrarrce. Our workers are futly covered by Workman's Compensatian Nofe:This proposal may ke
Insurance. withdrawn by us if nat accepted within days.
.��CQ���17�� �fF �'l2�j,c�Sc�r"'The above p�ices,
specifications and conditions are satisfactory and are hereby p�teofAcceptance:
accepted You are authorized to do the wark.as specified. Payment ,
will be made as autlined above.
Air Tech Services, Inc.shalt be en#ittsd ta receive payment€or any and a8 costs S�9natute•
incurred in enforcing,and collecting unpaid balances due(including reasonable
aktomeys fees),whether sult is brought or not end whether incurred with collection,
trial,appeal or otherwise.
Signature:
Brooksville Printing (352)79G-3512
�
Feb. 11, 201� 7:20RM No. b2$7 P. 2 '
q„ � SE'1"�'LEMEiriT STA'['E1Vx�NT & TYgE OF fAAN
Star Title PaR'�ners of'��mpa,LLC '. ❑�A a• ❑�x'+ 3- ❑c�,Y,uN,NS.
5020 Wesc Linebaugh Ave,Suite 14fl a. �vA s. �cotsv.�xs, 'i
T�mpa,Florida 3�62A, ar�etvurt�oa: �.��: I
(813)314-�6633 fax:i813)319-6444 Tpl�,q�yr I
f.Mm�geQ.e tns.C�seltva
C.NOlE; Thas fnrnr ts furnlshcd to gh�you a stalement ofac�aaf sen nt wsts.�4�noums paFd ro a,rd by rhe seldemerrr age,�ore skown.![enrs marked �
(pocJ were Aaid ourside di�closr� They are shown here tar irtjnrararea�t+t pqrposea arrd ane�at Pi,cludRd Pn ike totals. -
S�IIRI,IE M.BLACKWELL,a single waxnart
D.Byye�: 38444 C07`fONWOOD PL.
Zephyrhills,Florida 33542 -
�tonsld P.Martin and I�o�e A.Ma�rttn,as Trustces of the�tartitt Farnity�evocab2a Trust�►�nent dated
E.Solfec: Decernber 1,200�
35124 Deerfield 4aks Drive
ZsphvfiiUs,�'L 33541
�'.l,ender: CASH'
3$4�4�CQTTONWOOD PL.
G.Pt�ppetty: 7.ephyr$ill�,Pasco COUtity,Flo�ida 33542
l.ot 1 D8,Driflwood SaDdi�ision III.Bootc 27,Page i5,Pasco CountY.Flarida '
H.Settlemerut Agent: Star T�tle Perttters c�f Tampa,LLC
�'1ace oF Setttement SUZO West Line6augh Ave,Suite 14Q,Tampa,Flarida 33fi24 Hillsborou�tt Counry
I.Ssttlemgnt Dste: Janu 28.2015
J. Summary of�n3'e�''s'!'raQSStci�ou K. Summary af S�ller's Trans�etitin
1pQ.Grnss Amount Due Frem�t er. 4Q0.Grnsa Amaust Dae To Seller.
101. Conc,act Sales Price Ud0.a1 441. Gontract Salcs P�ice 80,040.00
!02. �ctsana��ra 402. PerSOnai Pro
t03. Settiemv�tt Ch to B cr(li»e I4Q0� 373.Q0 403.
Ad'ustments far Item,s�rid b Seller uk Advaace: Ad a�tnxents#or Items P$id b Seller lo Ad.vs�HCe:
!d6. Ci /Town Taxes 406. /'ibwn Tsxss
107. Coun /Parish Taxes 401. Coun /Patish Taxes
108. Assesst�ter�rs(H�A)J&n Z8,20�5 thru 1an 31, ?A,6S 408. AssesmtentS(HQA)lan 28,2Ut5 tl�w daa 3 t, 24.65
2095 2015
2015 Nen Ad Yalorem T�ze.s Jan x8 2�15 tluu 2015 Non Ad Valarem Tnxes Jan z8 �0�5 Quu
109. Ax 3I 2t115 ' i7.41 �9: p�3 t,2015 ' 57.41
17A. Gross Au�o�unt Duo frnm Bn er: $Q�Sl.�► 428. Grnss Am�ount Due t�Scller: 8d 075.0�
10�. Amou»tS P�id b or in Beh�lf ot'H e�: SQO. R,eductio�ns in Amannt Due to Ssller:
201. D osit/Eacnest M�e 5 004.00 sOt. �xcess Da ' sx instructions)
,,,,2p ;� ,� .' .�mouni.ofNewi.oan 502. Seulement�harestaSt[ier(LinetqOa) 6,512.78
`�43�3'':�.._ SQ3, f,ycisti I.O�S
LV'Mt��A��1��"i"� :�}.'"::%`: � 504. P �fof�irstMo
20?:.�'" ^'�"r^°`"�':^�''..:..�r�', 5fl5. P�offofSccond Mort�e
'� r�� �'�r W mr✓"'�'i"4�
e�i-�� �.�.
2Q6. ',::y;,�;,.:?��f,��<^�,s��y�: i 54b. Fu�hace MoneY Martgaga
,�:.�:_,. .
Ad.':'._ _ '�` � ' i�d Selter: i A.,d pstmen�for Items Un id b Sell�r:
210. �4i �'h�j`'Y�"•e s 510. Cety!'ibwn Tsxes
�y Covn1���.. , . -,;�;"'^7A15 thiu.lan 27, �OO¢J ' t Gou4ty1 Parish Taxes Jan 1:2d25 t►vu Jan 27, 88.54
G��. ZQ�$ ��t'ri''r. 4;ky4�i",•:r.�:r.: RV.J'+'� Sil.
�:�>:.c...�<..��.v;:��,���;� � 2015
212. .:.�.4v'�'.w�'�-tS:'r'''`�' i Sl�. ASSCSStAerifS
-- �•,.;�F'..y e.r'.�t�,^nt`'' - - -
iyxr.••,,;����'..u4:::,.
T � �,� fi ��•'•'�� i Totaf Reduciions in Amount Due
224 0 1 d'��,������:;, 3,Ii8834�529. ��er. 6,6Q132
:5�:;;,,-�:;;�"j'' 1
"",°�� "�'�f.�to.8n er: 64Q. C'$ab at Settlement to 1 from Sellec:
300. Cash atSei�`�ioRetf..
�0l. GroSs Amatmt�3ivAit Bu �i�te l20 8Q,431.06 601. Gross Amoustt due to Seilet lina 420 so,�?8.D6
3Q2. LeSS A�tr�ount Paid ifor� r line224} 5,088.54 b02. Lesz Reductrons Atr�aum due S�!!er(lino 520) 6,64l.32
. � 303. Cas4 Fro�Buyer: $75,362.32 503. Cash To Sel���': �73,476.74
.:�`{.
Feb. 11, 2015 7:20R1� No. 6287 P. 3
rne�tum6�r: ��+94425
SetdemantDate;,fanuary28,2�t5 WES'fCQR 14-49946
L. � � Settlement Charges
700. Totgt Sstes/�rnker's Commission: Paid firom Paid from
Bastd�tl�'Nce $80,000.00 @ 6.Q0% = S�i,800•00 $uyet"S Selier's
Division oiCommissien�s faflows �u�ds nt Fands st
70t. Z,TS0.00 to GN E ci�s,LLC dba Kellet'Wiiliams Teim rtics ���a� ���'�°t
702, 2 OSQ.OD to CENT[1RY 21�ILL NYE R�AL'!'Y
703. Cosnmissi�t Paid ai Serttemank �.
704. gAe 70'l:$S�GN Enterprises,Ll.0 dbal�ellef Williems Tampa Properties,�2743dosepb KiPping
705,
$0�. ltems�a bl�in Conneciion with Loans
$Ot. Loatti pti 'nation F�
802. Loan Disc4utt� �
803. A 'sel Fee
804. Credit tte ►t
8p5. Len et's lns ion Fee
$Ob. Mo IosuraRCe A icetton Fce
$47. Assum tion�ee
gqp, jbe�ri8 uilrcd a Leader to be Paid qq Advnaeo:
90[. Daiiy imeresc char fro�►1an 28,�OtS '
902. Mo ltisurance Premiwts
943. [�la�rd insw�nce Prcmium
904. Flood(nsurnnce�remium
1000. Reserves De sited with Lend�r:
1001. Hazard[nsu�a�nce
IQ02. Mort Insannnce -
l 3. C' Qro Taxes
100a. Coun Pro T�cos
l405� At�;;tiuel Assessmeirts
�X00. Title Cha
!lUl. Se�lemeqt or Closin Fee to Star Tit1e Partnets ofTem LL� 350.00 350.U0
1102, AbstracE ax'I"��Srm'c�t to We�roc l.and Titte Insluance C� 75.OD
tt43. '
f 1�4. �tle I�nsw�nce Bindor -
lIOS.
i 146.
1107. attosney Fe�c
(inctudes abovo item nuntbess:
Tit�e Inaw�tce to Westcor Land Tide insut�tnce Co�npany
!108. (it►eludes above item c►t�mbers: 450.00
.. .�� . Lendet's e O.t10
-:�d:;'Utvnei's C 80,000.00
�;r;�,����:l:3�r=���idg�itl�lnsucance�Statuato 5urch to Wt�tcor Land Tide Insuta�,ce�om 3.�8 •
`z;w: ';;�'p�iea.Y�tecordia and Transfer C4a es;
:.,;�^.� I;�w ., ", : .. ,�:�:• Deed IS.SU Mor.t e U.00 Releases QAU i8.50
'""^� 'z s: Deed 0.00 Mo e U.00
'f2'ti3;:"`SdG��'. :s=. Deed 5b4.W Mo e 0.04 56U.04 .
i2a.4-3r �•'!(�;t�i°;�.�Ic•o€thc Ci�uit Court
i245:.w; .`":• '�,.::•`.lifile 4.50 4.50
12U6.':'� ' ;�C��it►eCCira�it+�urt lO.OQ
1�00. A. --,.-,.,� .. .
130 9ti'`. %'yc�%':���'�:'�':;�'rta� • �
:,�.
i302. est:• ��•w ��;,<�•
t3p3. Cl �.���Yo�r. Lev 250.00 �
l3U4. ��;;:r:•��:y •>: �
..•:�,c. .e.��`..�'af....:;;,.
13U5.
13416.
13U7.
1308.
�309.
1310.
13l l.
1312.
1313.
a314.
13I5.
1316.
1317. �
i
1404. '�ota!Settlement Charges{�ater on line 103,Section.f and line 502,Scstiaa I� ; $373.QQ� 56,5�2.78
Feb, 11, 201� 7:21AM No. 62$7 F. 4
NOIY�TURE�GN CER'�'ICATIO�T
SY TR�ITSFE�O� �
1. SeGt�o�t 1445 of t�e �teriusf �evextue Code purovid�s that a tsansfe��e o#'a Uaited St�oes re�l �roperty inte�est musc '
Withhold t8x if the trans$eror is a fqie�pergo�p.
Z. �n order to infarm the transferee th,at wiitbho�ding of ta�c is not r�quired,ugon the dispositlon by af the United States r�ea!
pm�eny locpted in Paseo Counry,Rlorirl�and describ�d as�ollows: �
�o# Z 48,lariflwood Subdivis�an TT�a subdivision as�ex p1$t thereof as recorded iu�
YT�
�'lat�ook 27,Pa,g� 15,in the Pui�lic Records of Fasco Cou�ty,Florida.
Th�undersig�d transFer4r Cortifies and declares by rn�s oFthis ceriafication,the�attawi�:
A. Tran�s�arar is �,at a nonresident alxe� �o�c purpbses of United Smtes income
taxation�,and,
B. Traa�'eror's United�s taxpayer idemi�ication numbez Is:�943$-0406
C. Traa�s�eror's Home or Qf�ee Address is:
35�24 Deerfield Qalcs DrlNc
�ephyrhillsy F1,335�i1
D. 'i'here are no other pe�on;s who have an ownersI�ip int�rest in the above-described pzoperty other than
Transfqor.
T 3. 'I'he twdersigned hercl7y�iu�ztr cetti�es and declares:
' A,. Transferor undecsm.nds that the purchaser af t�e abave�descn`i�ed pxope�ty 9rctends ta rety on
t1t� foxegoing t�epresemaiivns i�conmection with th�United�tates�areign tnvesimeztt in Real Pmperi�'
Tax Aet(�4 St�te 2682 as amended).
S. Transferor understands this certiftcativn may be dfsclosecl to�b;e Irltern�l R�v�nue Service by transfiere�and
�aE a�y f�lse staceme�t coittained in this cert�cation may be punished by�ine,imprisonntent or both.
Under genaldes af perjury the�wdersigued d�c�ares that h�has exam�ned ca�efi�ly t�is certificacion and it is tzue,correct and complete.
DATED this Janu�xy 28,�QXS.
��ra.��l�� �5{��tST�� o� '� th+�k7t� ��n�i t�Y�,.�u�'
Itonald F.Mart[n,�s Truatee af the Marten Fsmily 1�evQCable -Sclkr
Trust Agneement dated 1�ece�ber�,2U49
�
����� ��� .
Hoge A.iVlart�p,as'Xl'ustee of the Martim Fa�ily Revpc�ble - Ilor
Trust Agrecmeu�t Qated Decemb�r 1,2009
STAT�OF F(or�da
CbLTNTY�F Pasco
I I HEREBY G�R,TX�'u'tl�at t�foregoing inst�vr4ent was actaiowledged,sworn ta azid e 'bed before me this � day of
�orea.�/ . � ,20�5,by Rnnald�.MBrtiti sk�d kZope A Maztitt,w do parsonaity lc�ow ar who tzas produced
l7''Gn � R.-ssl�� E:,r't� �s id tia did ke�aath.
. ��Q
NU LI�
Printed�la e: �.,�4 +�t v G'�:�'�'•�...._
My Commission Expares:_ — --
;,q�z��.. �^...4.6�t'f�iC1C PtllaP,t�r':�7. l�
�'�•''" T"� " �'i(ij�'a=4hit�7�'.
'C;�`r �?N . 4.;S�I�i'�3� ,.,.� ;i,,�;
,tr;w„'l.•�;i �1r::'3,S.���l�ti:•�:uaa..�s.-ti:.,�
k•. •.w L.r ..A..t�'f-�.°,�cf}� ..,a;
Feb. 11, 2Q1� 7:21AM No. b287 P. 5
Sattiem6nt Date:.tanuary 28,2tI15 File Number.TF14425
� .. , . �
a. sETr�.�M��r sTAr�M�r
Star Titic Pa�ners o��ampa,L��
5020 West Li,nebaugh Ave,Suiro 140
Tamps,�'larida 33624
(813)3t9-6633 fax(813)319�G�4
I heve carofully oeviowa!tha Scttleme�t Stabemca!aad to lhc bpt of my(mowledge sad b�ief,it is a tnee and ao�w�ate statemep,t pf a!(racsipts rmd disbursemeNs
made on my ar�oount or by ma in this tt�actFon. I ficeher ceriify�uat 1 have reaivcd a oopy of Settlemant Statea�ent.
g,uy�; r'"��a..�fC�-'`�� l��������e!�� Srl�ar `�.�-�Ot'"r`�/` � �p'� �� "��'kS�� I
SHIRI.IE NL SLACKWELL Ramsld P.Martiq as'Fn,soeg
�2• ���.,� .f,�.�w�a�
Seller Hope A Ma�tin.as T�ue �
The Settlemem Statement which Z have ptepared is a t�ve ard acevrate acw�mt of tbis trafisaction. f h8�ve caused ar wiQ cause t�e tiu�ds to be disbwsed in
accqrdeatce withthis slate�ew W6STC0814�19946
Settlemert A �ate: ]aouary 28,2015
�
Le�my GiemenW
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