HomeMy WebLinkAbout17-18821 CITY OF ZEPHYRHILLS
: " 5335-8TH STREET
(813)7so-oo20 �/9 821
BUILDING PERMIT �
� 'PERMIT INFORMi4TION � - LOCATION INFORMATION ' �
' Permit Number: 18821 Address: 4619 W ISTERIA DR
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: WHISPERING OAKS
Est. Value: Parcel Number: 15-26-21-0160-00000-0030
Improv. Cost: 6,442.00 OWNER INFORMATION
Date Issued: 8/29/2017 Name: HELMS JOHN & COBI
Total Fees: 70.00 Address: 4619 WISTERIA DR
Amount Paid: 70.00 ZEPHYRHILLS, FL 33542-5647
Date Paid: 8/29/2017 Phone: 813-715-2759
Work Desc: REROOF SHINGLE
CONTRACTOR S APPLICATION FEES
' SOUTHERN PRO RESTORATION REROOF RESIDENTIAL 70.00
� �
- (Q �
_ �
Ins ections Re uir' d
DRY IN ROOF INSP
TAPE JOINTS ROOF INSP
FINAL
REINSPECTION FEES: (c)With respect to Reinspection fees vvill comply with Florida Statute 553.80 (2)(c)the
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
i 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 BEFORE C.O.
NO OCCUPANCY BEFORE C.O.
,
� �
CONTRACTOR SIG PERMIT OFFI R
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
�
,, a�s-Taauo2o City of Zephyrhii{s Perrriit Appiication F�:-s��-�ao-eo��
�. Buifdir,q Dep�stmc�nt `
. DatQ ittieelvod phone Contact for Permittinq �3 . �O��o- 3��
_7.��_�.i l._�.�..i. �-L'C' >..L_.S7"a'Ll..:i. I i�Ci'1 C'71..�...�f'*�..r ....
Ow�or's Name . P� Owner Phons Plumber� " l��0<1 �
Owner's Address "lVl` W'S�ld �( Owne�Phona Number .���
Feo Simple 7ltleholder Name �'J -- `� CSw�ier Phona'Numbsr ( �
Pce Simple Titiehoider Address � �
JOB ADDRES8 y(9��1 W�c��(iu�t,7�� �11��.���L1� �or# �._3 �
� s�ga�v���a� . UJn� � s �A����.�n� �5 a6 ai-d�o-o0000.po���
� � (OE4TNl3ED FROM pROPERTY TA%NOTIC6) �
WdRKPROPOSED NE�NCONSTR ApqfAlT � SIf3N � Q DEAi�LISN
e INS'fAl.4 8 Fi�PAlft
PROPQSED U5E �� SFR Q COPdM � 0711ER ���-�-��
, rir��t��coNsrRucnora [� , s���c:kc (� ��arn�. � s°r��G [� - -
bEBCRIPT101V OF WOt2K �Sh e) �F'UO�aW-C���t �'�rr'c5a2�}t- lk1l�'
, BUILd1NCz S128 �_ � Sq FOOTAGE _1�•� NEIC,iHT ��
. �
�BUILOING ' � ��I VAIUATIqN OF TOTAL CONSTRUCTiOtd \
Q[LECTRICAL ($ —� AMP SERVICE Q Pi20GftESS ENERGY Q W.R.E.C.
�PLllR'181NG l� , r��/ 1
�li l�CJ
. L�MECHANIGAL $ VALUATIUN UF MECHANICJiL INSTALLATiOt�t •'���
QGAS R04FING � SPECiAL"fY 0 OTNER
FlNISHED FLOOR El.EVATIONS FLOODZONE AREA �YES NO
BUI4,O8R .C6MPANY ��O�D�11 P� �'K�`�"�
SIGNA7URE ta�cis7�Fa Y i�4 r�x cuatc�q .Y/N
A�dress �`� License q ( �—t
ELEC7RICIAN COMPANY ������
' SICit�tAA7�RE ru:r,is'r�eo Y i N FEe curtst�n Y 1 N
kddreas __� Licensfli; �_
PlUfABER � � COMPANY �__+^
3lt3tdATllRE aEcrsrcaco Y i N Fs�cu��n Y!N
Address V`M.-� licQii,e# � �
M�CHANICAt. GbMPANY I
` - SIGNATURE �� rz�cisTEr�o` Y!N rceCurzReh Y!N
Addrosa �License 91��`�
OTHER � � GflAAPAtdY �
SI(3NATURE � � r�ais'rEN� Y�N F�s cuaaK� Y I N
. Address t.iconso��__� 1� ,
' � � � � � i:� � � i � � ii� � i � � t � a � � � � � �.�.� e � � � � e � � � � i � e � i � � � � i � � ae � � � i � � e � � �.� � �
RE510ENTIAt At[ach(2)Wot Pians;(2)sets of Buildi�g Plans;(1)set o1 Gnergy Forn�s;i't•C7-L"J Pemiit ior�ew sonsiruction, �
Minimurr�ten(10)workinc�day5 atiers4ibmiU71 data. Requfred ansite,Construci�on Plnns,Stormwat¢r Pians wJ Silt�onCt�insialiar.l,
Snnitary FOailiti�ss:&1 dump5ter;Site Werk Permit for siibdivisions�7nryfi projor.ts
COMMERGlAt .Aitnch(2}rnmplete sets of Buiiding Plar.s plus a Lifu Safely Pac,7s;(1)s4t nf Enargy.Forms.ft=0-LV Permit far new car�slruclian.
Miri,mum t�rn(10)'tivcrrkiny�ieys,aftor subniltlat dnte. R�quirc+ai ansile.Constriict�an Piens,Siormwater P�ans w/51t funce instal{ed,
Sanitary'Fac�ilios&1 dumpstea Site Wcrk Permit for a1!now pmjocis:Al3'cammrsrcial ntqukemenls must meot compti3nCe .
31(3N PERMtT Ailach(2)sets of Ertglnsered Piz�n.s. `
••'°PFtOpERTY S1�RVGY requir�2tl tor ai11 NE�1 cnnstruction.
Diroctions: "
, Fdl out ap�ilc.�ticn cz�mpletaly. , , ,
t)wner:8 Confracinr sign back oPappNcatton;notarized �
!(avor 52500,a Notica oi Commencem�nt is requ(rad. jAtG upgrados o"ver$75fl4)
•• A�crnt(for ihcr canttactor)nr Pms�er ai Attontc�y(tor the owmGr),xoulri be s4mFann w±ih nntmrized letter fm�n owner aulhoriz;ng seme
- OVER TWE COUNTER PERM!ITING {wpy af cont�ct rcquirod�
Raroafs If shingies 5ewers Servir.a Upgtades Ni, Fences(f'IoVSun+oyi�r,rotagi�)
Ortvowayn•Nrt ovar Cnunter if on publio ruadw�ys..needs RO�h�
Nt3TiC�t}F D�ED RES"fRiCTiONS: The undersignec�unrlerstands that khis pnnnit inay be subject to"de�d"r�strictions,.
whiah may be more r�strictive ihan Counry regulations. "fhe undnrsigned assume�s rasponsibility for compliance with any
epplieable deed reshictiot�s, "
UNL10EidSED COtdTRACTt3R5 APiD CONTRACTi3R F2ESPONSiB3LITtE3: !# the owizer has hited � contractor crr
cnhftaciors to undortake work,they ms�y be required to be licensed in�cct�rdance with state and local rec�ulatinns. if the
contra�tor is nat itcens�d as required.by law,both:ihe owner and cantractor m�y be cltQcl for�misdsmean�r viotatibn� ,
� under state latrr. [f the awn�r ar i»tendsd contrackor are uncoriain as 2o wh�t Iicensing requirements may apply for fhe
i�lendsci work,they are edvised to contsct the P�sco Gcrtinty Buiicling inspection Clivision—Licensing Seatian at 7�7-847-
,8pi39. Furkhertnore, if tho owner has ttired a ct�ntractnr nr contractors, i�e is �dv+sad to have tha conirnclar{s}sign
parf[ons cif fhe"conirtcior Btack"of this application to�whioh they wiI!t�e responsible. tf ya�,as.the owner sign as the
contr�ctpr,thak.may be sn iridication tl7af t7e is nak prop�rly.licensed and is not entitled ta perm�tting privileges.in Pasco.
County,- ` .
'TftAtJSF?ORTA71t3�d IMPAG31Ul'!�F"ftES 1titIPACT AMC!_RESC}liftCE RECC3VEftY-FEES: '�'#i�undersigned und�rstands
that Tt�nsport�tion linpaci Fees and F;ecourse F?ecovory Fees may apply to ihe.canstructlon of nev�bt�iidings,,change ofi
use.in axisting tiuildings,or expansian o#existing building�,as specified in Pascp Couniy Ordinance number 89-0?and
94-AT,as�met�ded: '1'he undersig��ed afso understands,that such.faes,as�ay b�due,wi!!be idenfified at tl�s tim�.of
permitting.. {t is fi►rther understnod that Transpurtati�n.Impact Fr�es snd R�;sour�.Reco'very Fees must be paid p�ior to
receiving a"certificats ai'occupancy°ar iinal.pawer rei�ase. if the prajeci.daos not invoive a certificafe of occup�ancy or
� Ein�l pawer release,the fiees must be p�id psior ici�errt�it IssuanCe. Furtherrnare,if.Pasco County UVaierlSewsr 4mgact
, fees are due,they i�nust be peid prior to permit issuanoe in accotdance with a�piicabie Pasco County ordinances.
- CONSTRUC'(fION L1EiN IAYY(Chapter Z13,Fiarida'Sta#utas,�s amended}: if v�luatian o�woik is 52,500.40 or more,I
cerlity that i, the appticant: have been provided with a copy of the `�lnrida Canstruction Lien �aw—�Nameowner's
Proteatinn Guide"prepassd by khe Florida Department nf Agricul#urc��nd Cvnsumer Affairs. if the�ppticant is someone
�iher kh�n ihe"owne�",1 certiiy that i hava obtained�ca�ay ofi the above dr�scribed document and promise in gaod feith to
de4(ver.It"ic�the'own�r"priar io aamrrtencesrisitt.
Gt3NTR�iCTOR'S1{}{�NER'S AFFIC}AV17: 1 r,�rtitjr that atI the infcrrrnation in this app(ication is accurate enr3 fhst ei1 srrork
' will be dano in aompliance with aii dppiicable laws ragui�tirig canstructir]n,ioning and land development. AppfoaUon is
hersby made fc� obtain a pem�it ta do work arid installafion as indicz�ted. 1 ceriii�+ th�t no work or ir�sta!lafioi� tias
corr�menced prior to issuance af a psen�it ar�d #hat all wc�rk uriii be p�rforr�zed ta tr�esi standards of aq 3aws re�ulati�g
constructfon, Caunty and City codes, xoning.rr�gulaiions, and Is�nd development regul�tions in,the Jurisdiction. I also
certify tMat i understand that ihe rsgulations of aiher•gauernment ac�enei4s may a��ply to!he intended.work,and that it is
�y rsspons�b�iity to.ldentify what�cfions i mus�#ake to tae�n�mpliance. S�zcl�ag�ncass uac{ucie buk are nof limited�to�
- �spartrnenE ofi.E�ivironment�l Proteciion-Cy'press Br�yheads, W�tiand Arsas and Environmenteily S�nsi{ive
Lar�ds,WaferlWastewatar7reatmant. �
- 9outhwest Flortda Water ivianac�einent [3'tstrict»Welis, �y{�ress Bayheads, Wetland Areas, Allering
Waterc�s�rrses.
- Arrny Corps of Engir��ers-Seawafls,tJocks,t�avigable�Wr�terw�sys. .
. - D�p�rt:t�sn€ ai tfealih & R�shabii'stative SetvicaslEr�viros�nientai Eie.a!#h Unik Vdeiis, Wasiewa#er Treatment,
5�pt1c Ta��ks.
- U�Envirnnnten#a!�'rotectian Ac�ency-Asbestos abatement.
- Federa!Aviation Autharily-Runways.
- t ursderstand ihat the iottowing restrictions aPpIY ta#lan use of fili:
- Us�of fill'is not allpwed in Flood�one"V"unless expressly permiited.
- If ihe �i11 materlat is ta be used in Flr�od �ona "A", it is understnead that a drainage pi�an addressing a
- "cotispensatir�g volums"will be submifted at tim�ot permift�ng s��ick,is preparod by a pra€essiona!ettgiaser
licensed by ttie State of Flarida.
- if.ihe.�11 msierial is to be used In-F'laod Zane "A" in cnnneetion wi#h a permitted buiiding using stem waii
etrn"struciion,l certity th�t fi!4 will be used oi�Iy ka fi1I the arsa within the sterti walf..
� - if fiii materiaf is ta be usmd in any erea, 1 certify that case nT sunh fili will nof adversely affect adjacent
�prapertias. (f use ot fiil is found to`adversely affier,t ad�acent prbperties,tNe ownermay be cited for violaiiric�
lhe�ond'stlt�ris ot the buitding p$rr�tit issusd urfdec the attaChed psrnait applica€ion,for ldts€ess than oste{1}
acre which ars eievat�d by fili,an.engineerad dr�inage plan is requirad. �
If I arri ttre AG�NT FClFk TH6 OVIfAlER,1 proinise in good f�ith to inform the own�r of the permitt(ng cnnditions set fnrth in
this a�davit prEc�r Lo oammencing cnnstn�ct'son. i understanc3 th�t a separate permi#snay be requirad for�IscUi�al work,
. , piis�nbii�p,siflns,weils; puo#s,�ir cor�ditioninp,9as,or ntE�er instsllatians noi speciiic�lly in�lud�d tn the appEict�tian: A �
permit issued shalFbe.constnied to be a licens�to proceed with the work ard nat as autYinrity to viaiate,cancel,alter,or
set aside any pravtsions nt the t�citnic<�ai codss,nar shatl Issusnce a4 a perrnii prevent the Building O�ciai fram thereafter
raqutsing a correctit�n of errots in-plans,cansiruc#ion or viblaiions ofi any codes. Every permit issusd�h�li become invalid
unle5s the:i+vark au#hnrized Liy such permit is commenced within six ma7khs rrf parmit issuance,c�r if work auihorixed by
the permit 1s suspended ar.abandoned tar a periqd of six.(6).months after the time tha wrnrk is.commenced. An e�ctension•
�tsy be re.q€�est�rl,in writing,frrorn the�uilding t7(fscia(€or a period nc�t tx��xceed ninety(�t#)days and wili demtsnstrata
jusiifiabl�cause fior.,the exlonsion, if wnrk ceeses tar ninety{90)consea,ative days,ttie Job is considered abandoned. .
` WAt?t+tiN�3ty E#Wt�3ER: Y£tUE2 FAILUfiE T�'}t2EGORD A IdOT[GE t}F Gt3N1MENCE�itEidT MAY RESUL'F li�YUUR
�PA'f1PlG NUiCE�i3R IMPROVEiVIENTS:TO YOUR PRCfpERTY. iF YC►U tRiTEPiD TO' �INANCiNG,GCENSULT
ITH Yi3UR 1. N1Q R qR AtJ ATTOR Y BEFi�RE EC RRItr1G Ypt1R NOTICE A OM #UCEhAEI+lT
� FLOftiDA JURltT{F.S, 97.�
OWNEt2 QR AGEHT /�,�'����,�L� , COMTRACTOR —
3ub,acrik�ad end swo o ar Affirma bpfare ma th15 Subsnribatl and swarn to ar irmedJ before thia'
by«-���� �'Y._�(�i�t ���
W istere r�srsa a3�knowo ta ms ar ht�sths�va produced ,�l piszare oersonsit�knavs�T to me ar hastnave pr�rfuced
� �1,yf�S _��crfis�� as ieenliBcaGon. �' as Iden�cation.
.�"
���y_i�t ��Nnfary_Public W_____ NbtsryAubiic
��tasion No.t'"i� ti'p��`t� ,_„ _„_ Con�missk+n No. � �
12.,,- 0'� ar���
N�ane No ry typed,printeci vr stampnd ; ' ' Nama of Notary typr�d,�rintad or stam d
YFUite
°a .i� -�•-. C4TY JOHN�ON
�Q,••. `' MY CpMMISStpN!���07197� -
�ti.Fi��;�;.,, TQPfYMR4N MARTlNEZ n �. = EXPIRE8:F�bEu ���1
� ,; �� MY GQ►1MISSICM�1�GG(1�3040 . .�..�r �Y r �
�•� EXPIRES'.Match:6,2421,.,'�,- 'x",�,��a Baru4�0iTi�ufJafaryPr��}r�l�v►it�
� �QF�iA*�� �flQdd��Pl�u�l$' - �
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201712�583
PertnitNo. ParcellD No 15-26-21-0160-00000-0030
ep : ec: 10.OD
NOTICE OFCOMMENCEMENT �S: 0.00 IT: 0.00
State of fiorida County of Pasco 08 f 15/2017 eRecording •
THE UN�ERSIGNED hereby gives notice lhat improvement vnll be made to certain real property,and in accordance with Chapter 713,Flor(da Stalutes.
the following infortnation is pravided in this Notice of Commencement:
1 Description of Property: Parcel identi�cation No.WHISPERING OAKS PB 14 PG 86 LOT 3 OR 9478 PG 3664
Slreel Address: 4619 WISTERIA DR Z[PHYRHILLS FL 33542-5647 PAULA S.O'NEIL Ph.D.PASCO CLERK 8�COMPTROLLER
2. General Description of Improvement Re-Roof 08/15 f 2U17 O 1:09 PM 1 Of 1
OR BK PG 8��
3. Ovmer Infortnation or Lessee infortnation if the Lessee contraded for the improvemenl:
HELMS JOHN&COBI
Name -
4619 WISTERIA DR ZEPHYRHILLS FL
Address Ciry Slale
Interest in PropeAy Owner
Name of Fee Simple Titleholder
(It ditterent from Owner Ilsted above)
Address City Slate
4. Coniractor Soulhern Pro Retoration.LI.C.
Name
9260 Bav Plaza Blvd.Suite 501 Tampa
Address Ciry $Yale
Contractor's Telephone No. 813-835-1209 L
5. Surety:
Name
Address City Slate
Amounl of Bond: $ Telephone No.
6. Lender•
Name
Address Cily State
Lenders Telephone No.
7. Persons within the State of Florida designatad by the owner upon whom nolices or other documents may be served as provided hy
Section 713,13(1)(a)(7),Flonda Slatutes:
Name
Address Ciry Stale
Telephone Number of Designated Person:
e. In addition to himself,the owner designates o�
to receive a copy of[he Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes.
Telephone Number of Person or Entiry Designated by Owner
9. Expiration date of Notice of Commencement(the e�iralion dale may not be before the completion of construcbon and final payment to the
contractor,but will be one year from the date of recordmg unless a different dale is specified):
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT
ARE CONSIOERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART 1, SECTION 713.13, FLORIDA STATUTES, AN� CAN
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,CONSIJLT
WITH YOUR LEN�ER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT
Untler penalty o!perjury,I declare that I have read the foregoing noticepf commencement end Ihat the faqs stated iherein are true lo lhe besl
of my knowletlge and bepet. �
� �
STATE OF FLORIDA
COUNN OF PASCO �` /� yy�/�--
Si re o(Ovmer or Lessee,or Owner's or Lessee's Authorized
i rlDirectorlPariner/Manager
�� V\����
�Signatory's Tiqe/Office
The toregoing insWmenl was acknowledged befare me this�day of�,2C{�,by �J �� �� 1 ��1 i '� ) `,
as ��� �� (type of authoriry,e.g.,officer,lrustee,attomey in tacl)for
�- �u�`LS' 1�`�, � " (name o(p �on eh if of who i stru enZ was executed)..
Personally Known❑Q$Produced Idenlificetion� !.N�otary Signature
Type of Identification Produced FL�L'� I�I 'f5Z'T��—IUa1ne nn� �
+'�M'•""''•. S.KATELYN ESf'OSITO
�� �'�" MY COMMISSION tl FF 125878
:*: '.;
�; ,�o; EXPIRES;May 22,2018
�R'�t,.�'' 8onded Thru Notary Public Underwriters
wpdatalbcs/noticecommen ce ment�c053048
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��I���� Cu,stomer Ip; ����� License�X�GCi3295S#
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Customer's Hame{tnsured} " "` {�yg�omgr's Addtrss. � ' y tustomer's Ci1y,.Stase,Zip
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�'��'t+? '.li°�'�'+{.1� �? ���� �r`. ��..�'�'!�' �`� � ` ' � ti�r�t t�€�. .�'�..;��� -.
'CuStomer's 9est Phone�$Yime� tustumcr',Alt Phane �7a
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5hingie Calnr Note:.Harn�awn�r c�nfi�ms he/sh2 has p�rson�lly v2rified the type,styi�,and colnr..a�the shing{es e,��t,ai: �
' selected and homeowner.atc�pts futl resannsitiittrv for obt�inan�any necessary H�A app�ovals.
RCtt3f WCdYIC Ti�ta1(Afl i�uildings); 5Ct• rnittai: t�the�' 1r�itiat: ._,��_..
1Viain 6uilditig etached Buil�in Remove&Reait�c at�ie
5hingle Ivt cturer"�i lY°r�,.�"rll�3r�- _�� Gara Remove spos�:5ate8ite
���� `���"��"� ���--�-�.�"s
Shingls Mfr.Warranty:. tr ' S d Re ove&Reattach Anterma
;5fiingle.Color. ��`���'�'�'�� C7ther(See Not�sj Remove&Dispas�Antenria
; 3tottenJUn-Nallable wqad:We wili include the reptarement of twa A`x8'sheets ai OSe esr CDx decking�To maich exisitng ,_... �
decking).,Each addicional sNeet vai11 be;instailed at S45.Ci0 each.Zx�iruss scabbin�wtl be�ailled�c$3 per lE.Zx4�nii Zzcb �n�tial: �.�.=
�ascia wiN be 6iiled at$4 per'i.E:.Safiit.tvili.6e tiitled at$5;per LF.Pi3ies.do nat include patritsng:
Su�piem�nt�CAuthorization ��,�r,�i: Installation P�ym�nt i������= , °'- .�
1�gr�e to a Southi�rn Fro-Restarati�n tr�requ�sf suqplemen funds frsin Hosn�owner a�ree�to r.elease:the arnoun etaw �
�iray iiisu�ance coinp, or mistak�s;items ri�iss m�c6`�t p ice incr�ases, incfu�ing the insurance dedun�bie/upgrades(uniess
overhead.and profir,efc.that ay not be reflected an my in�urance atherwise ag�eedy Yo Southem Pro Restoration,on.th�
S�ttt2ment Sta . .agr�e to:r2lea�'� �mental funds to Sauthern Prp day of tristaii�tion.Homeown�r agre�s NOT td.u+rttihold
Rest ' n if appr�nved.This vuifl nac•affert tNe amoun 'i�Yf�ue-xo pay aut-of- this payment over.�ninar conszructic,n def�cts;J disputes,
pocket. Amaunt 17u�:ac InstaUation:$
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��}gWd��S tniY�al: �� P��/I71@tl� Initiai: + '�-
£�(�`�c i��y t•t��t;. �� �'✓ s,C..
Shtngie ilrifr,lNarrann'� YR, SQ. S , Rt�tif:.$
a�,
t3�ip£dge Colot: `'�,'��I J"�� 1.F. 5 tJpgrat�es:$ �'��_...
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T�tal Up�ra`de�;$ Stib Tcital:$_ �;tY��'� –
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Additic�nai Terrri�f Nates Total Paid Today:�$. ��.�� 'I
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� L���� p �� ��ti�,� , 'Total 0ue fs the amourtt du�priar io ai!-suppiements
�"'�� ��` � '�'�" ��� � andjor overhearl and profit.,
� G� � 1 , `������A A�.�'"'�'—` A 1 rights and afaSigations"o the,parties shaii be su ject ko'
"`� ��'t°`' '�"i and gaverned by the�"eneral Terms an�l Conctitions.a�'
P��� � .��
' i w rev�rse side,amendsnent(sj{�f appiica6l�),and this si�ned.
- . �1��"7 ���t ���"�"" Roaf Work Order 1��voiee includi��g any subse�uent
rnodifications�re hzr�by iricorporated by r�ference ani�
�ct�c#ied as Exiiibit(s)i�uiy accepfed arid si�iied by,btith:
parties.Rit work.au rized wi p 1N7thiti thp 1rOfk SCi7�5£Q�
fftiS�RQbE Ofkt# Ef i7Vbit@ �
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Cu�o ,ei's Signature Oate . uthorized�gen�5ignatur� Phone
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Custnmer°s Name(Printedj . Oate. Authqrized,�gen1'Name.(Prinied) Datz
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