HomeMy WebLinkAbout16-17421 CITY OF ZEPHYRHILLS .
5335-8TH STREET i"
(813)780-0020 17421
. � BUILDING PERMIT
PERMIT INFORMATION LOCATIO,N INFORMATION �
Permit Number: 17421 Address: 5422 8TH ST HISTORIC j.
Permit Type: RE-ROOF ZEPHYRHILLS, FL.
Class of Work: ROOF REPLACEMENT Township: Range: Book:
� Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 11-26-21-0010-12000-0150
Improv. Cost: 5,626.00 OWNER INFORMATION
Date Issued: 6/07/2016 Name: MOREL, JAMES & JOYCE
Total Fees: 97.50 Address: 5422 8TH ST -HISTORIC
Amount Paid: 97.50 ZEPHYRHILLS, FL. 33542
Date Paid: 6/07/2016 Phone:
Work Desc: REROOF METAL-APPRV'D BY HB
CONTRACTOR S APPLICATION FEES
TRIPLE CROWN ROOFING INC REROOF RESIDENTIAL 97.50
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� Ins ections Re uired '
DRY IN ROOF INSP
TAPE JOINTS ROOF INSP/ _
FINAL (n-�--��.f/
REINSPECTION FEES: c With res ect to Reins ection fees will com I with Florida Statute 553.80 2 c the
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local government shall impose a fee of four times the amount of the fee imposed for the initial inspection or
' first reinspection,whichever is greater,for each such subsequent reinspection.
NOTICE: In addition to the requirements of this permit, there maybe 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 pertormed in accordance with
City Codes and Ordinances. NO OCCUPANCY BEFORE C.O.
� NO OCCUPANCY BEFORE C.O.
�%C�
CONTRA TO SIGNATURE PERMIT OFFI R
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
�
o�a-�a�-�,�� Giry of Zephyrhills Permit Application FaX-813-780-db21
Building department
Dat�a Receivsd �,.•p''�C}—�� Phone Contact for Parmittin O�.3 �3.�,!' — �7�d
Owner's Name �,l4oytv 5 /Yi,/ flwner Pfione Number ��_��3w��
Owner's Address ��� l�,Jr�SU 1�t-- � �, !"d. �� � ��gr Phone Number _,.,,_
Fee Simple Titleholder Name � Owner Phone Number � �
Fee Simpla Tltlehalder Address
J08 ADDRESS �/ ��~ �'T• Z /�t+I�s �L"' 3..��ys� LOT# E�
susoivisioN �� � P,4RCELID# //-�b ��1--�at� -/�2000 �-0/�b
(OBTAINED fRQM PRQpERTY TAX HOTECE}
WORK PROPL?5ED e �Ew coNSTs 8 ADDlALT � 51GN � Q DEMQUSH
INSTALL REPAIR
PROPOSED USE �] SFR Q COMM � OTHER
TYPE OF CONSTRUCTION Q BLOCK Q FRAME �] STEEL ,
DE8CRIP7iON dF WORK �GGC✓ D� SY!/h l�.'S 5`�!/ L"" / �rA r
BUILDIN�SIZ� SQ FOQTAGE �SC7� HEIGHT �;7��� (1�
QBUILDING $ ���� VAI.UATiON OF TQTAL CQNSTRUCTION ��G�*�
�]ELECTRICAL $ � AMP SERVICE 0 PROGRESS ENERGY [� W.R.E.C.
QPLUMBING �S� � �
OMECHANICAL $ VALUATION OF MECHANICAL.INSTALLATION
`�'� ! � !/
QGAS � RQOFING Q SPECIALTY [� OTHER
FINISHED FLOOR ELEVATIONS ��� FLOOD ZONE AREA QYES NO
�
BUILDER COMPANY �'�
SIGNATURE ,� ,_ REGISTERBD Y/ N FEE CURRE� Y%N
Address License# � ��
ELECTRICIAN Ct?!�lpANY
StGNATURE REGISTEREO Y/ N FEE CURRES� Y!N
Address Ucense# �^ i �
PLUMBER � � � COMPANY
SIGNA7URE REGISTERED Y/ N FEE CURRE� Y/N
Address t.icense# r� ` �
MECHANICAL COMPANY
SiGNATURE REGIS7ERED Y/ N FEE CURRE� Y/N
Address l.icense# � i �
OTNEi+t � CC3AfiP/�NY �/`�`!s� .Oa:Ji! �v ��'7 1N�'"'
SIGNATURE REGiSTERED J N FEE CURRE� /N
Address �j7� ''� �i� � ��S �.� y1 Lice»se# �C���y�},3'7Q �
RESIDEN7IAL Aftacfi(2)Plot Plans;(2)sets of Building Plans;(1)set of Energy Forms;R-O-W Pertntt for new caanstruc8on,
Minlmum ten(10}working days after submtttal dafe. Required onsite,ConstruaBon Plans,Stormwater P�ans w/Siit Fence installed,
Sanitary Facilltias&.1 dumpster,Site Work Perm9t for subdivisionsAarge pro�ects
COMMERGIAL Attach(3)complete sets of Building Pians plus a Life Safety Page;(1)set of Energy Fortns.R-O-W Permit for new construction.
Mintmum ten{10)working days after submittal date. Required onsite,Construction Plans,Starmwater Plans w/Silt Fence fnstalled,
Sanitary Facillt(es&1-dumpster.Site.Work Permlt for ai!new projects.Aii commerciat requi�einents must meet comptiance
SIGN PERMIT Attach(2)sets of Engineered Plans.
""PROPERTY SURVEY requ3red for alt NEW construction.
biractions:
Fiil out apptication campletety.
Qvmer 8�Cantractor sign back of appflqtton,natarized
If over 32500.a Notice of Commencement ts required. (AfC upgrades over 57500)
" Agenk(for the contractor)or Power of Attomey(for the owner)would be someone with natarized letter from owner autharizing same
DVER THE COUNYER PERMITTING., .„ {Ftont of Appllcation Only) : � �� ..
Reroofs if shingles Sewers Service Upgrades A/,C Fences(Plot/Survey/Footage) " ` �
Drivewaya-Nat over Counter if on public roadways..needs ROW " . �
�OTICE OF DEED RESTRICTIONS: The und�rsigned understands°that this.pecmit.may be subJect to"deed"restrictions°
vhich may be�more.restr:ictive=than County regulatfons. 'The undersigned assumes responsibility for compUance with any.` "
ipplicable deed restrictions. � .
JNLICENSED CONTRACTORS AND �CONTI�ACTOR RESPONSIBILITIES: If the owner has hired a contractor or
:ontractors to undertake work, they may be required-to be:l(censed in accordanc�with state.and•local regulations. If the
;ontractor is not Itcensed as required�by law, both the owner and contractor may be cited for a misdemeanor violation
inder state law. If the owner or intended�contractor are uncertafn as to what Iicensing.requlrements may appiy••for the
ntended work, they are advised to contact the.Pasco County Building Inspection Divlsion—Licensing Section at 727-847-
1009. Fu�thermore, If the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign
►ortions of the "contractor Block° of this application for which they wrill be responsible. If you, as.the owner sign as the
:ontractor, that may be�an indication that he Is not.properly licensed and is not entitled to permitting privileges in Pasco
�ounty.
�RANSPORTATION IMPACTIUTILITIES IMPACT=AND RESOURCE RECOVERY FEES; The undersigned understands
hat Transportation Impact Fees and Recourse Recove.ry..Fees may�apply to the construction of new buildings, change of
�se in existing buildings, or.expansion�of existing'�buildings� as specifled in Pasco County Ordinance number 89-07 and
�0-07, as amended. The undersigned also understands; that such fees, as�may�be�due, wlll:be identified at the time of
�ermitting. It fs further understood that Transportation Impact Fees and Resource Recovery Fees must,be paid prlor to
•eceiving a "certificate of occupancy" or final power release. :If the.project does not involve a certificate of occupancy or
•inal power release, the fees must be paid prior to permit issuance. Fu�thermore; if:Pasco County WatedSewer�Impact
`ees are due, they must be-pald prlor 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
�ertify tfiat I, the applicant, have�been provided with a copy- of the "Florida Construction Lien Law—Homeowner's
Protectio� Guide" prepared by the Florida Department of Agric.ulture and Consumer Affairs. If the appl(cant 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'3 AFFIDAi/IT: I ce�tify.that all the Inf.ormation in thi.s application is accurate and that all work
will�be done in compliance with all applicable laws regulattng construction, zoning and land development. Application is
hereby made to obtain .a permit to do work.and Installatlon as indicated. I-certffy that no work or tnstallation has
commenced prior to issuance of a permit and that.all work will be perFormed to meet standards of ali laws regulaking�
construction, County and City codes, zoning regulations, and land development regulations�In the jurisdtction. I .also
certlfy that I u�derstand 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,ln.corr�pliance. Such agencles include but are.not Ilmited to:
- Department of Environmental Protection-Cypress.Bayheads, Wetland Areas and Environmentally Sensitive
Lands, WatedWastewater Treatment.
- Southwest Florida Water Management- :DisUict-Welis, Cypress. Bay_heads, Wetland `Areas, Altering
Watercourses.
- Army Corps of Engineers-Seavualls, Docks, Navigable Waterways.
- Department of Health & Rehabllitative Setvices/Enyi�onmenfal Health Unit-Wells, Wastewater-Treatment;
Septtc Tanks. .
- US Environmental Protection Agency-Asbestos abatement.
- Federal Avtatlon Authority-Runways.
I understand that the following.restricNons apply to the use of flli:�
- Use of fill is not allowed in Flood Zone°V"unless expressly permltted.
- 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 permltting which is prepared by a professional engineer
licensed by the State-of Florlda.
- If the fiil 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 tfiat .use of such fill will not adversely aifect adjacent
properties. If use of flll is found to adversely.affect adjacent-properties, the owner may be clted 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 flll, an engineered drainage plan is requtred. �
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 requtred for electrical work,
plumbfng, signs, welis, pools, air condttioning,.gas, or other.installatfons not spec�icaliy included-in the application. �A
permit lssued shall be constcued to be a Iicense to proceed with the work and not as:authority to,violate, cancel, alter, or
set aside any provisions of the techn(cal codes; nor shall issuance�of a permit pcevent the Buildirig Ot�icial from thereafter
requiring a correction af errors in_plans, construction or violattons of any codes. Every pemnit Issued shall become invalid
unless the work authorized_by such perrnit_�Is_comrvienc�d wifhtn stx.months of_permlt issuance, or ifi vvork 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, tn writing, f�om the Building.Official for a period.not to exceed ninety(90) days and will demonstrate
justfflable cause for the extension. If work ceases�for ninety(90)cons.ecutive days,.th�job is considered abandoned.
WARNING TO OWNER: YOUit.FAILURE.TO,RECORD A NOTICE:OF�COMMENCEMENT IVfAY RESULT�iN YOUR
PAYING TVYICE.FOR IMPROVEMENTS TO YOUR PROPER-TY. IF YO.U�INTEND4T0 OBTAIN•FIPFANCtNG;�CONSULT
WIT Y UR LENDE O AN ATTO NEY B FORE RECOR�D G YOUR- � C 'O � E M T�
FLORIDA JURAT(F.S. 117_0 _ ,� ___ _ .. - -
OWNER OR AGENT �`' ` ' CONTRACTO �
Subscribed and s to(or aflirmed)betore me this Subscribed and om to(or afflrmed)befo me thts
by '�
VYho islare pe►so ally kno to.me or haslhave produced Who.ls/are p onaily kno �to me or�haslhave produced
as Identlflcatlon. as Identlflcadon.
.i�. ta Public . %� � Notary Publlc
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Product Evaluation Report
GU�.F COAST SUPPLY& iUTANUFACTURING, LLC.
, . �
29 Ga. GulfRibT"' lioof Panel oarer 7x4 U!looa!Purlie�s
Florida Produ;ct Approval #11651.Z7 R2 -
Florida�Building Code 2014
� Per Rule 61 GZO-3
Method: 1 -D R�VfEW pqTE�`��
- � CITY pF ZEPHYRHI
Category: Roofing P�� �����R�
Subcategory: Meta9 Roofing
� Compliance Method: 61 G20-3.005(1)(d)
NON HVHZ
ALL WORK SHALL COMPLY WITH '
PREVAILING COpES
Product Manufacturer: FLORIDA BUILDING CODE,
' Gulf Coast Supply � Manufacturing, I�}�pF�PHY H'LL30RpINqNCES
14429 SW 2nd Place, Suite G30 ,
� Newber FL 32669 +`'''��"'''f
ry� .�' N1E� S. /�'�,
, �.�Qp,.. ,.. l� '�.
� `. ����Ns�yti,,
Engineer Evaluator:
. ,
Dan Kuhn, RE. #755'i9 e�_ No, 7�5�9 '; =
Florida Evaluation ANE ID: 10743 =" : ---- � �. _
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:�: sr ' :
ATE OF =Q.
Validator: �O�F .�< OR ID P .•���;�
Locke Bowden, P.E. #49704 %SS�'• •••'''�G� .�
�'� ;�NAL E�� �'
9450 Alysbury Place ''+��� '`'
Montgomery, AL 36117 °��3°j2°75
' Contents:
Evaluation Report Pages 1 — 5
i ;S
FL#11651.27 R2•JUNE 15,2015
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City of Zephythills
BUILI3ING PLAN REVIEW COMMENTS
Contractor/Homeowner: � ��
Date Received: ���l� ,
Site: ��Z2 ���
Peimit Type: �� � � .
Approved w/no cominents: Approved w/the below comments: ❑ Denied w/the below comments: O
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This comment sheet shall be kept with the pernut andlor plans. I
--� ' �-- —��
,
Kalvin S ex ans Examiner Date Conlractor and/or Homeowner
(Required when comments are present) `'
l llllll II�lI I INl lllll I Illl Illil Il lil lllll IIIII IIIII Illl IIII
201fi079108
� Permit No. Parce!ID Na -���{�-af�oro -/,�aoo -6 fs�� . ..__._. �
NOTICE OF COMMENCEMENT ,„ _„
5tete or_„_���'���" Caunty ot l`/�'��
7HE UN�ERSIGNEp hereby gives natico lhat Improvementwlll be made lo certaln real property,and in sccordance with Chapter 713,Flaida StaWtes,
the taltowing lnformation 1s pravlded in thls PSoSice of CommencesnenC f1 f�t-� � �/ o
�, pescriptlon of Property: Parcel identlficadon No.��l Q f Pl���.�9��jb s,LLX fZb Ot�I7�r=--Fi��Bd'2?'�7�r r��jG''3d'Q
Street Address:
�Ya� �P`" �f_�,�,�v u«<� '���11a 7�/6P.�
2. Generel Dasrliptlon pf Improvement /����
3, Owner�ntotmation ar l.essee infortnation it the Lessee contrected 1ot the improvemerit:
,�'",o+�+�',� /1'1 O 2e'L -
_�.�� s�a���.so.0 Y11z ?.���i2�c.:4.� �L 33��-
Address ^` ,��� City 5le[e �p�
Interest in ProReRy._ GW _- �t{/�p
Name of Fee Simpie Tilleholder. �� \••�
(If diHer-�ent�- er Ilsted abave) m��
�� �
N t9►1
�``a`�� T�'G�JIf" f�1t�1�<1 �11d�iitJl /R,lL��` s`�`� �'�'�
4, Conlractor�
�/l�eme��02i� D/"� e.'�'",�,c�� /�/L..L �`z- 3.�� � ?
Address �^�J }� Gity State .
Contractors Telaphone No.: t?r3(��'��� /�0 3 M
• ��
5. Surefy. � ` " �
NBtne i/ �
fY ��-•
Address City Stata ���
Amount af 8ond.$ Totsphone Na.:
A m
6. l.ender. "' �
Name �
7
Address City Stsie �
Lenders 7elephone No..
i ?, Persons vi,thln the Stata of Florida designafed by the ovmer upon wham naNces ar other documents msy be ssrved as provided by �
Section Ti3,13(i)(a}(7},Florida Statertes: �J/
�v
� Name
Address Glry State
Tetephone Number of Dasignaied Person: {{m a
8, In addition to himseH,the ormer designates of„_ �N a
to teceive a eopy of Ihe Lienors Notice as provided in Section 713.13(1)(b),Florida Statutes. �p�N
, Tetephone Number�f Person or Entity Oesig�stad by Ormar: x NN�
z
9. E�iredon date of Nolice of Commencement(the e7tpirafion date may not be hefare the completion of construation and final payment to the ���
' contractar,but wi11 be ane year from the date of rer,oMing uNess a diEtererit date Fs spectHedj: ��"o
t+s
WARNINQ TO OWNER: ANY PAYMEN7S MADE 8Y THE OWNER AFTEi2 THE EXPIRATION OF 7HE N07TCE O�CCIMMENCEM1dEiYT
ARE CONSIDEREp IMPROPER PAYMENTS UN�ER CHAPTER 713, PART 1 SECTION 713.13, FLORIDA STATUTES, AND CAN N�
RESULT!N YOUR PAYING TWICE FOR IMPRqVEMENTS TO YOUR PROP�RTY. A NOTICE OF COMMENCHMENT MUST BE ��D
RECORDED AND pOSTEB QN THE JOB S1TE BEFORE THE FtRST iNSPECTION. iF YOl!lNTEND TO OSTAtN FtNANCtNG,GONSULT 3 �
WiTH YOUR LENDER OR AN ASTORNEY 9EFORE COMhiENCtNG WOAK OR REC4RDING Y�UR NOTICE OF COhiMEtSCEMENT. o
Under penalty of perjury,1 deGare that I have read the faregoing notice of commenaement and that tha tacts stated therein are true to ihe hest C�'I w�
of my knowledge and belief. m
A
STATE OF FLORIDA //�/��/, �
COUNTY OF PASCO _L�l�f ���% ��
Slg�fature or essee,or OwneYs w Lessees Authorized r o
OfficedBlreatodPaMertManager �"'f �
�{�..n„��ixt�� � �
A
0
5ig�tory's�f ille/Office r
1,,j t(2+4,}�f m
The toregoing insintment was aclmowledged�}iefare me thi day o 2tJ�,by���t STY
as �44,.`� (type of allthority, .g.,officef,ttuslee,attomey In fact)for
' cE ytG , , name bf on 6e,ha�wf�o +nsUument wss executed.
{ �� .�d=�/'.,"'l�i„^-�., �
Personally Kno R Produced Identlfication❑ , Notary Signatu��_�'
Tyge of Ident'sficatian Praduced Name(Printj
` - NOTARYPUBLIC-BSTAS`TEOF�F ORIpA
COMMISSIOM#FF038413
i
EXPaRES 712212017
j80NDED THRU i-BBg.ryOraRv1
I ti mencement c 3U48
wpdatalbcs no cecom � D5
���v�� �
�� '� o �i� S1AT��� ��.�Ri�bA,�OU�TY��pASCQ
`�� C1 HIS IS TO CERTIFY THAT THE FOREGOING IS A
� a ��`' � � � UE AND CORRECT COPY OF THE D�CUMENT
��d � �� FILE OR OF PUBUC RECORD IN THIS OFFICE
� , ��, �eT�r � IT ESS Y HAND AND 0 FICIAL SEAL THIS
� � .� � � DAY OF 2�,_�
°� ,�8�j , � AULA . O'NEIL, CLER C PTROLL-�R
�;,.�� � � �
'�`���'���p BY �'G� ` DEPUTY CLERK
� , • •�/• •►�•_� '►�1�'_•
n���r• ���r
TRIPLE �ROW N ROOFING, INC.
7I40 ANDRE DR. � ZEPHYRHILLS, FL 33541
$13--833-�7720
STATE LICENSE CCC049370
WWW.TRIPLE-CROVITN-R04FING.COM � LNAULT1963@AOL.COM
SP�C�ALIZING IN ALL T Y'PES OF METAL RQf�F SYS�'�.NIS
NAME PHQNE DATE
JQ�►�S /�d,�, f ��3 - 7�y -338�f� �. -j-�G
STREET GlTY STATE ZIP
s�a� 8'�` cS'�-, I ,�I�.11s rr�zz .�3sy�..
SALESMAN �f�
iG..L B�l CZlJ `7` �3'''77 c,�(�
We hereby submit specification and work description:
�it� o o� �.S"�i.� �.�5 t'� lQ c� ��� t,,,,,aa� �StG G�oS]�s ��
� 1 � / /
/NST��I G'L J4 t'd! � �"Ts GK UiZGZY.i'l4-y.n�-i'�►� l� 11 a'~�/ ��G�L rrt.¢
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f/1/`S�t/I L�? ,�t f� -1��j /1'!-��"+�l �"p D �-=i n �a n�S � c���l
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�,r''�r�s2. t,C C r"s. � r ,�� r rl r�S'� t� L!G,G�}-G u�s 't.,..
P � ,,� �
,/ft G� j/p Glt•i.j�-�"'s � r� ��L/.�rt r ,/1/t,u..�r�''��l,s �s •'".s�e, i� c�"'u.*—�
a � /
7�L L'' s P/7i/� d C�y � Gl t"'!s n �/� �
1 I
THE ABOVE DESCRIBEQ WORK WILL BE COMPLETED ACCORDING TO SPECIFICATIONS, FOR THE SUM OF
{$ a����_}. PAYMEN7 TC}BE MAgE AS FOLE.OWS:$ ��.�'�► AS DOWN PAYMENT
BALANCE 0�$ ��v /� DUE UPON COMPLETION.
***ANY ROTTED WOOD DISCOVERED WILL BE AN EXTRA CFiARGE AT A COST OF$ ��PER 1l2"SHEET OF
P�YWOOD$ , S�� ' �in. Ft. Lumber.
NO tJRAL AGREEMENTS HAVE BEEN GIVEN QR ACCEPTED. THIS WRITTEN CONTRACT IS THE
ENTIRE AGREEMENT C4VERING ALL THE WC?RK TO BE PERFORMED ANDIQR MATERIALS TQ BE
FURN(SHED. THE WRiTTEN PORTION ABOVE IS THE ENTIRE CONSIDERATION FOR THE AMOUNT
OF TNE C�NTRAGT. PURCHASER MAY CANCEL THIS CONTRACT ANY TIME PRIOR TO MIDN[�HT
OF THE THIRD BUSINESS DAY AFTER THE DATE PURCHASER SIGNED THIS CONTRACT,
IT IS AGREED:
Contractar wiii do a!1 said work in a good and warkmaniike manner and in sfrict accordance with the ordinances,rules and requirements
of the city, Town or Village, wherein the above mentioned praperty is loca#etl. If purchaser should cancel this contact after time statetl
above,the Purchaser agrees to forfeit down payment paid. In the event it becomes necessary for Gontractor to emplay an attorney to
collect any sums due the Gantractor pursuant to this contract, then the Purchaser shall pay all reasonable attorney's fees incurred by
the contractor.This contract shall nat be binding ugon Contractor unti!accepted by them. Upon such acceptance by said company,this
� contrac#sha(I be binding on melus without any further notification fo me/us.The undersigned property owner agrees that this contract
, may be assigned for the performance Qf the wark and labor required by the description of the work to be performed, Upan assignetl the
parties hereta consent to the performance of the work by and payment to such assignee of the amount of this contract,Any Alteration or
' deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over
and above the stated contract amaunt.
NOTICE TA THE BUYER : (1)Do not sign this contra�ct before you read it or if it contains any biank spaces.(2}You
are entitled to an exact copy of the contract you sign. (3�Under the!aw you have the right to pay off in advance
fihe fult amaunt due and under certain circumstances to obtain a partial refund of the time charge. Owner acknowl-
edges receipt of a true copy of this CONTRAC'f.
r�' G -/--�
PURGHASER DATE
. ����,�
Y: riple Crown oof g, Inc. DATE PURCHASER DATE
This cantract is enfarceable only whe�accepfed 6y management of Triple Crown.
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�P�LdCAT9�� ���A H���'C3�� �rs��e�r ;
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s`��R�'lF1�ATE CAF At��'R�lPF�1/��NE��" � ._ �
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eysmt�Applicaffon#�{'/����� �'orrtributirrg: es ,V� Date Su6rnrTfec�: _ �
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^ , ��AP��Please provtde ktferrna#oa t►siwear�ttte ddtrbt�lir�es)
�4 PrOperty Adrlre5s or lot�tion: ,`���� -.. � f� -���t°,t..,� �,�,�P,t��17,��l S �,1! �-�,� '�=aC. �
` � � � �J�/ r-� �
Ch+met's Name: (� rY1D� � J L"�t�� _�"I.�..�..�r� PEwme: ��3��5 �S "�U L I f
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APP�ic�nt's N�ne 8�Gampany(�f�fe�: �
ApplicartYs Ma9�ing A,ddress: `��1��,'�i 14�11�"�: .�h;,� �,�1 I S_�_ C
APp.Cbntac#Info: Phone:_„�.'�,.�2_I��:�����Faos;3� �mail: '���„w�.;p (}�7 �1��7T/�7?rg�L-CvfrJ (
Ty�ae c�f�Prope�ty: Resi�ent�l� Cornme� �ubiic or t'�ther
9
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PROPflSED RESTORATfON!RENOVATIOIVS I REPIo�RS/RELCIG,�ATIOIY!ETC: E
6der3or-Fll/alls • � S(�na9e (
E�deriar poars • �3glM�sg (
,- 1NMdaws 3dstiv Mai�BeaEldfng or Aslctitlan ba 6asling 8u8dng f
Pal�he�s t�taw AR�ce�sary.BSdg.(garage,carpo�t,shed}
arp �
Awnir�gs or�arwpies �sw aectc,ramp.pa#o,et�c. I
Fenang E3uitdlrtg,Demflii�on or Re�acat�an }
E�derior Fairttit�g&Cabr Changes �enera!Repalrs(rlescribe betov�J i
.. ,�Roc�fir�g � Otfser(desrxsb,e be}aw) i
� ' r
aet�te+d desc�ti Dan cf pro ed wock� (at�aett otner sheet��`n�sary} - � `' �
( c' . . � !1 F - ) r . �
. .. . . ._ _ . . ;
_
.
- • • . - - � � - - �- - -- - - ----._— __� ._.... ;
The F�s�o�ic f't�serrairon 8o3rd�eqtures tttat!he fa�Eowt�ng lrtfarmatic�MUST be InUuded with an appilca�n pcio�t�t�e � �
�ir,�on belrsg accepted by sh�F � �
. Detalied Plans,iactuding a ' lan and e(gva n($h
'• �,.1or�d meterial sar��:
• ManuFac�urers¢�.1 s iit�a#ur�: �
• ,�tont�cr(�ectd
• My Ottier suQnctrt�{g documer�tation tq show that the proposed work Is conslsterrt with�t�e adapted Qepart�teatt
of erFctr S#a�sdards.
� �� , `� _ �..'�
SlGNA THE OWN APPt.lCANT'� r�
� fAppl'rant da IwOT w�e B$OW�1ris J�ne)
�.�--
AGTION TAK�i: Date. -' {✓;
�8y St�: A��ved�, Densed Reasgn fcr Dental:
�8p HPB: Approved Ap�roved with modificatiortis nated betow'andfor an attacbed sheets
Derried
'NPB Cct�ditior�(s)af ApprovaL
signed: oate: �P
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