HomeMy WebLinkAbout17-18597 �
CITY OF ZEPHYRHILLS
5335-8TH STREET
� ` (813)780-0020 18597
DRIVEWAY PERMIT
� PERMIT INFORMATION - LOCATION INFORMATION==
Permit Number: 18597 Address: 5308 19th St
Permit Type: DRIVEWAY ZEPHYRHILLS, FL.
Class of Work: DRIVEWAY/REPLACEMENT Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
' Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number:
Improv. Cost: 5,700.00 OWNER INFORMATION
Date Issued: 6/21/2017 Name: COLEMAN CECILIA& SCHNEIDER DAVI�
Total Fees: 40.00 Address: 5308 19TH ST �
Amount Paid: 40.00 ZEPHYRHILLS FL 33542-4619
Date Paid: 6/21/2017 Phone: �
Work Desc: DRIVEWAY 57.5 LENGTH 16.10 WIDTH �
� CONTRACTOR S APPLICATION FEES
HOMEOWNER DR EWAY 40.00 ;
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Ins ect�ons Re uired
DRIVEWA �
FINAL I
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REINSPECTION FEES: (c)With respect to Reinspection fees will comply with Florida Statute 553.80 (2)(c)thel
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 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 I
entities such as water management, state agencies or federal agencies.
The payment of inspection fees shall be made before any further permits will be issued to the person owning same ,
"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 I
before recording your notice of commencement." �
Complete Plans, Specifications and Fee Must Accompany Application. I
All work shall be perFormed in accordance with City Codes and Ordinances
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CONTRACTOR � PERMIT OFFI
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO �
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED ;
PROTECT CARD FROM WEATHER i
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a��-�eo-oo2o City of Zephyrhiils Permit Application Fax-813-780-0021 �
Building Departrnent .
Date Recelved � �i .� Phone Contact for�Permittln . —
Ow�er's Name ` v 1 ►�l � Owner Phone Number � ✓ �
Owner's Addrass ��� �' Owner Phone Number �
Fee Simple Titleholder-Name Owrier Phone Number T I
Fee Simple Titleholder Address
JOB ADDRESS � LOT# � �
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SUBDIVISION P.ARCEL ID# ! ' D��tJ J ((.(�'�(� `�(� � I
� , (O TAINED FROM PROPERT1f,TAX NOTICE) �
WORK PROPOSED. �:NEW CONSTR' ADD/ALT Q SIGN Q Q DEMOLISH I
•,e.� INSTALL ,� ; REPAIR � - �
PROPOSED�USE , - � SFR - [� �COMM � ' Q OTHER � �
TYPE OF CONSTRUCTION Q� � BLOCK ' Q FRAME Q STEEL Q I
DE3CRIPTION OF WORK ' s'` 11L l� �� �7•,� ��P • �v
BUILDING"S12E � � � � S�FOOTAGE � .HEf,GHT , .,
�BUILDING $ �- �d,� ' - , I
� � VALUATION;OF TOTAL CONSTRUCTION I
QELECTRIGAL $ " AMP SERVICE Q 'PROGRESS ENERGY Q W.R.E.C, i
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QPLUMBING $ _ � i
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QMECHANICAL ' $ VALUATION OF MECHANICAL INSTALLATION
QG�4S Q ROOFING Q SPECIALTY Q OTHER
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA QYES NO
BUILDER � i COMPAN,�(' ����-+�. I
SIGNATUR _ �ISTfl�D Y/ N �FEE CURRE� Y/N I
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Address ' � � Cicense# '� � ,'
A, , ,. �
ELECTRICIAN• : . .CpMpqNy - • � I
SIGNATURE � REGISTERED Y/ N FEE CURRE�`t ` �'Y/N
Address � � � ,-. License:# � I
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PLUMBER ' : , . � COAAPANY � ; , �. . , i
SIGNATURE' " ���` „ REGISTERED.. Y./.N�. :- :rFEE CURRE�. •- '. Y/N.
Address � . Ucense,# � _ I
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MECHANICAL�� . . ` COMPANY . , � , � I
SIGNATURE - _ ' -" ' ' ' � . , � �
F3EGISTERED Y,./ N , ; FEECURRED . . X,/�N .
Address; . `r � . � .. - .t: .- . ' Licens,e# . - i �'
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OTHER � -',� . - ` " - ;COMPA"NY , , , t � �
SIGNATURE .. . : , ' • , " , . '� Y"` ,
'` "'^ 'REGISTERED' ,' Y/ N..;. .Fee cuw��" Y/N�
Address �- ; ..�, • , � . . � License#�' �
C. , .-•_�.. ..,.-...._', T` 'Sr�ti.:' :. ,. k�:.:.: . .. . : ' .., , e ,- - .' i�. � I
RESIDENTIAL; AttacFi;(2)„PIot�P.lans;;.(2)sets`of�Building'�Flans;''(1)5et'of Energy.Fortns;,R-0=W'Per_mitfor new construction, " -
+7 i ri. •;
-� -_�a-Minimum,ten-,(1.0);working;'days atter�subrriiftaFdate:r.Requlred onslte,:C:onstnicdon:Pians,'Stormwate�"Plans w/Silt�Fence tnstalled, �
� �Sanita'ryFacllfties:&�;1,*dumpsterrSlte�Work�,PermitfocsutidivislonsAarge;projects; -`;-..:: - ' � � �
COMMERCIAL Attach(3)`com'plete set's�of Builtlin`g"Plans plus a Life'Safety Page;(1)set of Energy Forins.R-O-W Permit for new construction.
Minimum ten(10)working days after submittal date. Required onsite,ConsUucUon Plans,Stortnwater Plans w/Silt Fence installed, �
Sanitary Facflides 8 1 dumpster.Site Work Permit for all,new.proJects..All commerGal requirements_must meet compliance '' I • �
..SIGN PERMIT Attacfi(2)sets of Engineered;Plans:,s--.,. ^-=- : � .. � �
""PROPERTY SURVEY required for all NEW,construcUon. . �
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.Directlons: .. .,.., , . i
Fill out epplicaUon completely.
Owner 8 Contractor sign back of appltcaUon,noharized � I
If,over 52500,a Notice of,Commencement la required. (A!C upgrades over 5T500) , '
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Agent(for the contraoto�)�'or Powe`r of Attomey`(fo�ttie owner)would be'someone virith notarized letter from owner authorizing same �
�VER THE COUNTER.PERMITTING- --- �(Front-of-Application-Only) ., .,� , , � I
Reroofs If shingles Sewers , Service'Upgrades A/C,'� ' Eences(PIoVSurvey/Footage) . , , _
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Driveways-Not over Counter If.;on publfc'roadways.:needs.ROV1l�' , • • i
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NOTICE OF DEED REST.RICTIONS: The undersigned,unders�tands;;th�t.tN1�:��rm�frmaybe,subJect,.to,°deed",restrlctl�ns",:,:�..,.,.,,_..,�
whlch may�:tie�rrmoire�?r:'estttat�ve=t#�a�CounEy'`r+ag�lat(on`s:��The�ndersigtied as`"sumes cesp�nslblllty�for'°coinpllance virifh�ariy`` " _. �.
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�ppHcable.deed'reshictions. � � , , _ .. �- ,. .
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UNLtCENSED�.CONTRAGT4RS .AND C4NTRACTOR RESP+DNS18lCITIES:= -:!f�the��owner=has��htced"'8�'COCltftiCtOP OT
coniractors to under#ake work, ttrey may<b.e;r�quired_to:<'b�;itcensed in:accardance.with state.and;tocai:regulattons:�°tf�the��-��-° �� `�{
contractor is-not Ilcensed as�re'qulred;'�tiy lew, tiotir the'ovmer and°conUacto�-�mayYtie��clted�.fior•a�misdemeanor vtolaCton
under state law. 1f the awner or Intendei��contr,a�tor,ere;uncer#a1n �s tci whaf licensing requtrements:�maY��PPIYjf'�ac�ftie' :..,-. - =t
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intended work,�they are ativlsed to con#act,the Pasco=County.Bullding�Inspection,Clivislon-_-Ltci�nsin�Sectlon at 727-847-
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8009. Feirttiermo�e, if the owiier fias"�hired a cctn�ac#oT'ot contractors, he ts advlsed to have jthe contractar(s);sign, .,
portlons of the.°contractar Blockp.of thte_appilcafian for which.,they..wtlt.b.e.r.esponsibte.-r if,.you;�asr#he,oviine�`sign"'as'�he�" '"M �
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contractor, that�may be an Indiaatlon that'he'is not:properly'licensed�and�is-not�entiNeid"to pernifttirr%g�pri�iileges In Pa�co ..
CbUnt�t. ' . . ._ ._ _-,. . -. � ._ _ ,-r � _.. „. _ ,. :
TRAIVSPORTATIONjIMPACTIUTILITIES�INIP�4C'��AND RESOU�tC� RECCIVERY�FEES:"The untletsignetl understar�ds
that T��nsportation Itnpacf Fees end.Reco.urs�e.Recove.ry.F�es mal!:y�ppiy�:ta�tEye tcanstructfonf.of new�bulldings,�change'of-.=,. '..�°,'�
use in existing bulld(ngs, oc.;expanston��of��existin,g:hbufidtn�s, as specffied.In P�scq County Ordinance number 89-07 and:
90-07, as amended,:.�.The under�lgned also;understands, ttiait"such fees�-;as�may:be::due;,wi11:7�e tdentlfied at the�-tlme�of:#" ��'�� �-
Pem�itting. t# Is t�i'�tFier understoad that Transporta#ian Im act Rees and��'Resource..Reeoue�' �Feeg,musf be aid rior to
P ... � �` R P
recetving�a."cerfificr�te.�of nccupancy" or�flnal��power;release:- :If�Ehe.proj8ct�..does+;not�involve<a.�,certfftcate af occupancy.o��-�����-= ���'
final powec release;�the:fees mu�t;be paii!,prlor torpermi# Issuaqce. Ft��#her�mare,i�P�scQ;Count�:,V1'IaterlSewet=�Impa�c#• r �.�:�._..
fees are due,;they�must.be=pald..prior#o:permit�isst�ance�in.accardance witFi�:�applfaable:Pasco�-County�vrdinances. •
GONSTRUCTiON�l:lEN'�l.AW(Cfiapter 718,Elorlda 3tafc�t�,as�mendedj: !#valuatlon of work is�2�50Q.OQ.ar-:mor+�,�l-� . :�ae
aertify tNat �, the.�appiicant,- have:•been proytded.•with� a�=copy of.the�°Florida° Construction�`Lten.;Lav�--Homeowner's
Protectio� Guide" prepared by the Florida Departmenf of Agric,ulture and Consum�r,AfFairs. If the �pplicant is someone ;�: .,, ��,
other than the"owner"� 1 certi�r.#hat;l�.tt�ve.ob.tained=a�=coPY:of ths;above describe�lclocui�en#;and;pcori�lse:in:goadifaith�.to :.,.
deliver it to.the�"ownec"=pnlor'.to�carnmencement:" - . . ., . , " . - . - �-
CONTRACTt�R'�IaWNER'S AFFlDAYlT: i.ce'r.t�fy:;tliat�alt.-th�,lntormatlon:in this appitcatton Is ac�uraEe.$nd#hat all work
wili'be done in compi(ance with all.applicable laws reguiating constructlon, zoning and•,tand�deyelopment. Appitcation is
hereby made to obtaln .a.pecmit�:to do_woik:.,and Installatlon as indt�eted:-�=..�1. ceK(fjr 'that no wo�k`:or Installa#ton t�'�s'
aammenced ptlar to i`ssuance of�a perii�it��and`that�.al! worlc will be pertormed�to meat.standards4af all laws �egula�irug� _
CO�ISh'UCtI011� County and City codes� zoning regulatians, and land development cegulaUons=tn the jurisdtction.= I�al'so .
certtfy tha# # uc�derstand that the r�gulatbns of other gavernment agencl�s mey�apply�to the intended vtirork, and#hat�t Fs
my responsibility ta Identify�what,act(ans I musttake:M.be,ln_.cotrlpllance,_,,Such.agencies.lnclude but��are.nat IfmFted to: � _
- Qepartment of ErtvironmenEal�'Prutecttan-CypFess.'Ba'yh'ead�� We�and Areas and Envlronmentatly Sensithre
Lands,WateriWastewater Treatment.
- Southwest Florida Water Management: �.Clls(rict 1Nelis; Cypress."�ayheads; Wetland Areas, Altering
Waferqcourses. _ . .
- Army Corps af Englneers=Seawalls, Docks, IVavigatile Waterways. ,
- Department of.Health'&:.Ret�eb�litativ��.Setvtces/Environmental Ne�1tf� U'ttit Wells; Wastewaters Treatmen#, °
Septic Tari�cs: �' ` ` . , -, - - :
- US Environmental Proteotion Agency-Asbestos abatement. , �
Federa)Avtstlon:Autharity-Runways:Y -
I understand.that the,followang..'restcictlons apply'io ihe use of flil:�
- Use of fl!i ls noE atlowad in'Floa.d,�Zone"V"unless expressly permltted.
- If the�.�iil�mate�iat� is to �b.e used:�iin.:Flaod�Zone. "A", tt. is understood that a drainage pian addressing a
ucompensating volume" wlll be submltted at#tme of�perrnitting which Is prepared by a professfonal englneer
Ifcensed by#he State�of'FlaHda:
- If�h� flll materlal-is� to be used (n Flood Zone "A" In�cannection�with:a��ermitted�building using stem wail
� construction, l cerEiFy#h�t�Il:�ll:be�used only.#a�ill the acea wlthln ttre�stem�wall:
- If flil material is'to be used in any area� I �aertlfy that .use. of�such flll will not adversely affect ad)acent
properties, !f use pf flit Is found�to adversely.�ffect adJa�ent��propertles,_the owner may be clted fo�violattng
the conditions.,of the bi�ltding�;permit tssued�under the attached,�iermit apptioafion��for:lats�.iess�.than�one {1)
acre which are elevated�tiy�flit,a�t engMneered dralnage plan is requlred. .
If 1 am the AGENT.�OR THE t�Y1fNER� I;.�romtse!n goad faith#o I�foem#he awner of�the permit#tng cond€#ians�se#farth In
this affidavit`prior to commeracing construcflon. "I'understand theta<�eparate perntlt may be requtred for etectrical wark, ,
�.. .�..
plumbing�_slgns, wells�.,.pools;.afr condlttoning�-.g$s,..or ather lnstatl�ttotis not,spec�icai#y inclu�isd�tn.the appllcatlon. .A .
permit issuei!shali be conshued to be'�a°ticense`-to�proceed with fFite work and not�as.authority:to,.vtolate,-cancei; alter, or
set aslde any prodislons af ihe technical.c�odes; nor shall issuance�of a.permtt.prevent the Bulldlrig C?ffictal from thereafter �
requirin,g a correc#ton c�f errors In�plans;constractian.or_vlolations of-any codes. Every-pi�rmit�Essued sfiall become fiv�lid
unless the work authortzed.by such permit{s.commenced�within sUc months of�permit Issuance� or if work authorized by
the permit is suspended�or:abandoned�far-.a;Perlod;o��s�t:{�}mnntfis,:efter the tlme the�woi'ic-�s corrimenced. An extertsEon
may be requested, in wri#ing;�.f�om.the�Buiiding,Offlc(ai for a perlod=not-to exceed�ninety(90)���ays and-viiill�demanstrate
justlflable cause for.lhe extenston: If work ceases:far ninety.�90)cons.ecutive days...th ljab�is.consideted aba�doned.
WARNING TO OWNER: YOUR..�AILWRE•TO,.REC.O�iD,A::;MCITIGB:O .:� OMM6MCEMEMT•.NFAY-RESULT�IN YOUR
PA1t1MCs TWICE:FOR IMP'ROV'E,MEN�`S,TiO.sYgUl�:P�DPERTY:��I�Y�-_ ,-.----_:'E'Q�'�O�TA1N=f1Nfil��NG;�33N3UL.T_V_
WIT U D AN� '#TO N 0.��. OR�1 G.�� C�1 "O '. .� . E
FLORIDA JURAfi';(p.S: .1�:� .,.... .. ...._. . . . .,,. .. -
OWNER 4R AOEN7 f� NTRACTO ,
Subscrlb�d and svw f�� Ih Sub�bed and� m` ed)� ' e b ����
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are ers�anallyhnown to.me r ras/have,produced Wh s/are erson ily �o�nm•to me:or has/h ve�produced •
r�G2�+,S-e as I entlflcatlqn. �C� �k2ds �cr,n�'�,_es dendflcation.
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� Nataty Pubilc _ r�' Notary Pubitc
Co ssl ;�� ����„C���,_ „r, Com is n Na
+� 's.= Commission#FF 150d22 .•"�Y�i%'•�., JACQUEL'INE 80GES
Name of N =p iil� 9!� � Name ot Notery �eil r�Ueis�FF 150422
�'�,p„„�'` 8ondudThn�ttoyPeininnurancaSQ4385-1019 :;. :'a: Exp�res0ecember12,2Q18
�r'��S„o,�fL°�``�` gondsdihmTmyFaintnsuranco400,185.7618
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A���.�,p.�.� "'i;�,
PERMIT APPLICATION `"`�'��� ��
DRIVEWAY PERMIT APPLICATION
CONSTRUCTION WITHIN PUBLIC RIGHT-OF-WAY
All information must be filled-in completely
• City of Zephyrhills !
5335 8"'Street, Zephyrhills, FL 33542 �
Telephone 813.780.0000 Fax 813.780.0005 f
3Date of appiicafiion: ' ° - ; Prucessed By: � , Permit#: . - �
i ' ' � � (9way areai far staff use on[y} , - $
�Copy to Building Departmec�t ` �- [�Copy fo Pubtic iNorks - � �
PRO7ECT 70B SITE: PROPERTY OWNER
Address: 5308 19th St Ze h rhills FL 33542 Name: Cecilia Coleman
Unit#: Address: Unit:
Parcel Identification Number: Ci State Zi Ze h rhills FL 33542 �
Phone: 727 389-2314 Fax:
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CONTRACTOR: I
Company: A 8�A Development. Inc. �
Name: Arthur Richard_Carroll. Jr. ;
Contractor's License #: CGC1519991 E-Mail: ac(a)tampaflcontractor.com �
Phone: (813)622-8886 Cell: Fax: !
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ARCHITECT/ENGINEER: I
Name: Firm Name: i
Address: City: State: Zip: i
State License #: Phone: Cell: Fax: �
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Description of Proiect ;
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TYPE OF DRIVEWAY 57'-5"LENGTH OF DRIVEWAY CULVERTS NEEDED I
�RESIDENTIAL DRIVEWAY 16,_10„WIDTH OF DRIVEWAY ( )REINFORCED CONCRETE
COMMERCIAL DRNEWAY R.O.W. EXCAVATION ( )CORRUGATED MATERIAL
PUBLIC ACCESS DRNEWAY DEPTH LINEAR FEEf ( )BOX CULVERT
( )OTHER(IXPLAIN)
CONSTRUCTION MATERIAL CURB CUT REOUIRED
ASPHALT YES �NO
�CONCREfE
HEADWALL REOUIRED? YES X NO
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NOTICE TO APPLICANT: If actual work exceeds scope of this description,additional permits or drawings i
will be required. I
UTILITY LOCATIONS REOUIRED: CALL BEFORE YOU DIG: 1.800.432.4770 ;
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� 5a�a C�T �c Sr�w(�
*lsPl#�4(.T a� ��Q�.s 3�x? �
� ��a�sr��i�i
�- � p�� . �'�tE S dA�S
DRAWING NOT TO SCALE. �' Zx�,
Drivewa�r Area
� 16'10" -- �rr Tc►�C�C .�J�T►�li� t�BLIC f��G�ET OF�
1035.1 ft� t"���
Concrete Volume
517.5 ft3(19.168 yds3) ;
' S7'4-1/2•'
---��_. �
21'10"
25'3"
�--�— g' �
6'
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PERMIT ARPLICATI4N I
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�F�ICE t�SE QPILY � i
- - - -
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PUBL:[C WORKS USE QM1.Y � �
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- - - - _ ; I
. ;
Concrete_ (min. 6'�__ Y IV �
- - __ _ I
_ - -
'Asphalt Base{min. 6'� _ _ Y N� . _� � _
,A�phatt(min. ITfz` - — Y N _ .
+ C.ertgth{min. 19'} _:_.Y_ N - - -- - - - --- -
- - _. ._- �� _ _ - - - -
1N�dth(1Q'mEn-20'max} __ _ __ y; N _ - - - --
� Existing sEdewaE�, - Y � (� . - _- - - --
New sidawa(k._ _ Y ,�,� -- - . _ _. .- --- - -- ,;
ADA complianG Y iV "- ¢} ' - -- - - - ---- - I
_ _ - - --` ' I
� - - I
- - - -
- ..
Fxpansion materlal requlred. �Y N. ��.,�_ � Q'�.��--�� ;
___ - �` � � I
Cor�tiguous arlcing pad. 1( N, oN ''t'�i��u�'� �.,4�QC`t"��xi�c.i���.:G D�Pi.' 7b�fl��U,� �
, - - - � - - �
Triangular flare(3'W x 7`L) Y N �' _ ��
;�sibility triangle a.k.? � N - -- -- '
5ide set back(3'rnin. R.Cf.W,) ' Y N -- - - _
_ __: _ -- - _ _ -_ - - - - - ,
Plan Revieuir Fee . - - -
, Addii:ionat descti t�on.of wark as d�efit�ad�s .Pubtic-WaMrs Director and ar des➢ nee:--- �� � ' i
. --- - ;
�--�� �. -._ -- osa i���t aX - _ - _ _� ;
�_ _ ....,� --_- __ - - --_�
" - :
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Permit appllca�on approved by: �. �-�„- � Date: ,�'� �""U g�l"`� - � I
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,P@RM�'APPLICATION
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UTILITIES LOCATE CONFIRMATION NUMBER: I
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PROVIDE SKETCH IN THIS AREA, IF ADDITIONAL SPACE IS REQUIRED, ATTACH TO THIS j
APPLICATION. �
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AFFIDAVIT: Application is hereby made to obtain a permit to do work and installations as indicated. I certify that all foregoing
information is accurate and that all work will comply with all applicable codes. I understand these codes shall take precedence over all
approved construction documents,and issuance of this permit is verification that I will notify the property owner of Florida Lien Law
req., F:S. 713.
The issuance of this permit does not ensure compliance with deed restrictions and I understand that additional deed
restrictions may apply to this property.
� All work shall comply with the current Florida Building Code, Public Works Design Manual and FDOT Design
Standards(if applicable). (Public Works Design Manual online link:www.ci.zephyrhills.fl.us/public_works.asp)
APPLICATION IS VOID UNLESS SIGNED WITH PROPER IDENTIFICATION AND WITNESSED BY A PERMIT
TECHNICIAN OR NOTARY PUBLIC.
NOTE: The City of Zephyrhills is not responsible for maintenance or repairs of driveways. Driveways shall not alter/
interfere with existin stormwater treatment and/ or conveyance.
PROPER7Y OWNERS: By signing this applica on I certify tha rea and understand the owner/buil y discl sure
statement. CC (please initial)
Cecilia K. Coleman � � �
Applicant Print Name Applicant Signat re Date �
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Permit Technician Signature (or)Notary Signature Date j
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Applicant is( )personally known to me or produced as identification. ;
(type of identification) I
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06/21/2017 fC. R. M. , Dpty Clerk , j
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NOTICEOFCO�i3tV1ENCEM�IIVT' 'PRUGR S 0'NEIL,Ph D.FASGQ GLERK & G4MPTRQLLER ;
060R1BK 1�7���m PG �1�G� I
FemAit No. �-- -- -• -- - -- - -._ ..
�P�Y Identificatian No. i+����o��UQ�N'��i,�ll?���r"�77
TAE LTNbERSTGtVED fiereby�vo inSonos you thet the improvr.mrnt wftl be medo to eertain rasl pmperiy,ead'm eceordence wfth
Soctian 723.33 of the Flor3ds Statates,the foliowing' eflon�S pzovtded ia this PtUTiCI�OR MhiENCEi►SE j� !
, t.Lkscriptno-nofproparty( t a • �'��L� n ����t=�' i � u.} �G� � ! i
r�a�$htCt At�f�['tS9: �
✓Z,C��CIHI d4SCtIpCOn Of�t4YEII1EDtl: p
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3.Oamcr Wor�na8oa � ( .�'�✓fN'�t,.� , �J C�i,s ,��✓��
a}Name mmd address: Irf ,. j/ �
b)Neme ead addtess of fee simple titleho dcr('�f othv tl�an owntr) �
e)Interest ia'P�P�Y I
4.Gantraaorinformatiou � I
a)Neme aud address: �, /,�� n 1/l Q .�,_✓ . I
b}Te3cphane Na.: Feat Np.(Opk) �
S.Siaety Infofmatton � •
e)Nema md"eddress!
b).Ama�ms afBond: ;
c)Telephona No.: ' Fax No.(Opt.) �
6.C.ender
a)Neme and eddress:
Pholte No. •
7.ideatity af pezsoa withiu the Ststc of Plasidn�ealgaated by awner upon whom aotius oT at6ter dac.mnenta may be served:
a)Name and addass: ' I
b)Te2eithone No.: Fsz No,{Opt,)
B.Xa eddition ta himsel�owner drsip�uates tlia fotlowing pereon to nceixe n copy ofthe i,ienoYa Notice es�provided ia Seccian
713.23(1}(b�,Florida Sta6rtea: ,
a}Name pnd address:
b)Telephono No.: �. .. .Feac No.(Opt) �
.9�iza�on data ofNotiee af Commenamarit(tlu expitsiian date fs ane year frvm tlu daie of securdiag s a diffateat date is
spoci5ed):
WARIVING"CO C)tVNER: AYVY P'AY1VxF.1V'I S 11'�ADB BY THE OVyNEl2 AFTER TI�E�T�tATYON OF THT N07TCE OF
COMMElYCEM�I+1T'ARK COi�ISIDESSD IMPRQPER PAYMENI'S C7AIDER G'�AI�T'ES 723,PART I,SItG11UN?13.23.
FI:OItiDA STATIITES;AND CAN RESULT W YOIIit PAYITTG'1'�V7CE FOR IIVII'ROVENdETPI'S TO YOUR PROPERTX.
A IVQ'ttCE 4F COMMEl+ICEriiENT MU$T BE RECORbRU . POSPI�D ON THE JOB SITE BF.itORB TRE FiRST
INSPECITON.II+YOU YIVTEND TO OBTAqV FIIYAlVCII�iG,C� �T OIJk LX�NDSR OR AN A�TORfILY BEFt)ItE
COMMI:NC,tNG W08K OR RECORDING YOUit NUTICE CEMEN'I: .
F
SfATE OS FLOAIDA
+CO27MY OFPASC{7
• � S1 uY orlacd������91%�/`i..'i
PrintNmu �
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'Ihe regolug s tzvmc � ��aclmowledged bofara me this.G�/s�dap of'J��� .20�by
Y_����}�es Ac.r3n�J�^" (type of wrhoiity,e.�offi�cer,trustee,auozuey
m fi for � (anme af party on bebatf� instrume�w�s c�ie
Pecsonsi2y-Knawn—+DR-Praduced-Identtficst'toa�—••—�Iomry•B�ganfiva— / _ __.
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"rype of Tdeatlfication Pzodueed Tz-' �'"��(�.'"`"'"`""�ame(prmt) Q. (,l.E�:��1G e'..�
Verificas3on pw�suent to Section 42.525,Flodda Statutrs.Under pana}ties of perjury,I declaro tLat I have reed tha foregoing and thas
the fects stated in it axe true W tlze besk ofmy lrnowledge snd bette£
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ST�f� �� F�.Ot�fD�,, COU�lTY OF P,RS�t� .��' ° `Y � `��C�
i'FiSS iS 1'v G�RTIFY THA�'THE FQREGt�IEVG!SA �°O�, r'�, �
TRUE ANC)CC�RRECT COPI'OF TH� UOCUf�EP�T �,;, e �
ON FIC.E Ok OF PUB�IC RECC}RD IR THIS GFFIGE � � ;:_;: ''�,�=l�.F,
WITNESS,��HAND QFFICIALSEALTHIS rtec``�`�r'�"''r . �
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