HomeMy WebLinkAbout17-19062 ; ; CITY OF ZEPHYRHILLS
5335-8TH STREET
(ss3pso-aozo �A62`�~~
MOBILE H�ME SET-UP
�- - PERMIT INFO�RMATI'ON �� = LOCATION INFORMATION=
Permit Number: 19062 Address: 6755 36TH ST
Permit Type: MOBILE HOME ZEPHYRHILLS, FL.
Class of Work: MQBI�E HOME SET-UP Township: Range: Baok:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivisian: CITY OF ZEPNYRHILLS
Est. Value: Parcel Number: 42-26-21-0090-03000-0040
Improv. Cost: 4,600.00 OWNER INFORMATION
Da#e Issued: 11 i2012017 Name: OAK CREST LC.0
Tatal Fees: 180.00 Address: PO BOX 669
Amount Paid: 180.00 ZEPHYRHILLS, FL. 33539
Date Paid: 11/20/2017 Phone: (813)997-5337
Work Desc: lNSTALL MC?BILE HOME REPLACEMENT
CQNTRACTOR(�S APPLt"CATION FEES
T RY'S OBILE OM E UP MO ILE OME ECTR AL .00 OB L O ET- 6 .00
HOMEOWNER MOBILE HOfV1E MEGHANICAL 40A0 tUIOBIl.E HQME PLt1MBING 40.Q0
TERRY'S MOBILE HOME SET UP
HOMEOWNER
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Ins ections Re uired
M ILE H ME S�'f-UP
MOBI�E}iONiE E�ECTFtEC
M(JBILE HOME�
MOBILE HOME IVI
FINAL
REINSPECTION FEES: (c)With respect to Reinspection fees will comply with Florida Statute 553.80 (2)(c)the
taca!government sha11 impase a fee of four fiimes the amount of the fee imposed for the initial inspectian or
first reinspection,whichever is greater,far each such subsequent reinspection.
NOTICE: In addition to the requirements of this permit, there may be additiona! restrictions applicable to this praperty that
may be found in the public recards af this county, and there may be additianal permits required from other governmental
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
Complete Plans, 5pecifications and Fee Must Accompany Application.
All work shall be performed in accordance inrith CEty Codes and Ordinanees
,
NO QCCUPQNCY BEFQRE C.Q.
L�f:
� �
C NTRACTORS SIGNATURE PERMIT G1FFI
PERMIT EXPIRES IN 6 M4NTHS WITHOUT APPR4VED INSPECTIO
CALL �OR INSPECTION - 8 HOUR NOTTCE REQUIRED
PRClTECT CARD FROM WEATHER
, , . . �. .
CITY OF / / / / BUILDINa
ZEPHYRHILLS DEPARTMENT
OF ADDITION OR CORRECTION
� • • - •
ADDRESS DATE PERMIT�,
��' � ,�`�� - t-� -Z�LFJG-
THIS JOB HAS NOT BEEN COMPLETED. The following additions or cor�ections shall be made before the job
will be accepted.
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It is unl�wFul tor any Carpenter,Contractor,Builder,or other persons,to AFTER CpRRECTIONS ARE MADE CALL
cover or cause to be covered,any paR of the work with flooring,lath,earth 780-0020 FOR RE-INSPECTION
or other material,until the proper inspector has had ample time to approve
the installation.
OFFICE HOURS 7:30AM-4:30 PM MON.-FRI. INSPECTOR
813-780-0020 City of Zephyrhilis Permit Applica#ion Fax 813-780-0021
� Building Department
Date Received rl phone=Contact for�Permltlln , - `-t �
Owner's Name - tfwner Phone Number '"1�
Owner's Address �`'� � � ti Tl�ner Phone Number �'� '.��
Fee Simple Tltlehotder Name � • � Owner Phone Number �� �
,_ -
Fee Simple Titleholder Addre�s
� � �� � � C�
dOB ADDRESS �� �� tJ� {~ i LOT#
suao�v�s�or► •�_G�?���,�lS � PARc���d# �o� - ��..a- � `t�' ��� � �
/�.��„� � C_C`J Ll�� (OB7NNED FROM PROPERTY7AX NOTICE)
l..^
WORK PROPOSED - NEW CONSTtt� ADQlALT • �] SIGN 'Q [� DEMOL,1$H
':e. INSTALL � . REPAIR
PRQPOSED�USE Q' SFR [� COMM' [_� OTHER '
TYPE OF CONSTRUC'TION Q ' BLOCK '' � FRAME C� STEEL Q
DESCRiPT10N OF WORK � l��.r
BUIl.DlNG 5lZE' Ct���lc�X_I� SQ FOOTAGE.CL.,�.�—LJ; - - FtE1GHT .�._�
.._ ,;
[�BUILDING �4 ���t��� ' �-� � �
`""�ulJ�-J
VA�.UATION:OF i'C?TAL CtONSTRUCTION
[�ELECTRICAL $ � � AMP SERVICE " �] PROGRESS ENERGY Q W.R.E.C.
[�]PLUMBING� $ p� � l���
��� � �,/
. � f ,�-�J}��- �.�-
OMECHANiGAk. $ " VALUATIONOF'.MECHANICAf.INBTALLATION. "j�� fV�
�
QGAS Q ROOFING .Q SPECIALTY �] OTHER �� �
Si
FlhitSHEQ FLOOR ELEVATIONS FLQOp ZONE AREA QYES N �J j("�
�#
BUILD�R COMPAPIY �fti� �j
SIGNATURE ~ � REGISTERED Y/ N FEE CURRE� ' Y/N"
/iddress � � � 1�� License•# `._:_.`� �(�c���� �.��
ELECTRICIAN Gf COMPANY ' ` �'�� O � � �
$IGNATURE 's REGISTERED Y/ N FEE'CURREK' ' "�Y/•N
,., � , ,.
.
Adelra�ss �_�.�— _.___. _____.u� _ ... 1�fc,�ns�#-�----------- °.�- -
PLUMBEtt ` COMP.;ANY � `� � (� �
$IGNATURE� � . REGIS.TERED �./�N: . FEE CURRE� ' Y/N
Address � �� Ltcense# �•.�.,`� ,��1,�_�:
MECHANtCA1l` �z,��� COOAPANIf d �""�' ,.C'. ��i✓�v?/�4�' Y'
SIGNAT�JRE REGISTERED Y J N ;,FEE CuwtEn Y/N
Addres`s�= ' ' '' ' � License# �-'— —�
OTHER � , :; - ' ;COMPANY ` _ , � . ,
SIGNATURE "'� ` � ' ' ' � ` $ REGISTERED Y/ N . �FEE CURREh Y/N
Address . . . � - - Clcense# � 1
. , , ,:,�.:. .„ . :
RESiDENT1AL;�,� .AttacFi�i2);.PIo6P,lans;,(2)`sets:of�BuildPngiPians;(1)set af•Energy�Fairns;_R=0•-W'Perrrilt fc'r new constructian,
Minimum;ten=(1.0),wotking days;after;;submiftal:dafe.-Requtred onsite,:Gonstnic�orr Rians;Stormwater Plans wl S{It Fence instailed,
� �"Sant�eiy Facllltles:&;:1.,dumpste,r,,�Slte•Worlc�Permit,tor.subdiv,isto�s!large�pmjec�:s__; .:,�. `
I COMMERCIAL Attach(3)�ci�inpleYe�sets of Builidfes'g'Plan.;'plus a'Ufe Safety'Page;(1j se4 04`Energy Fonns.R-O-W Permit for new construcdon.� - --"-
! Minimum ten(90}warktng days after submittal date. Required onsi#e,Construc#lon Plans,Stormwater Ptans w/Sllt Fence instalied,
Sanitary Fac11(Hes&1 dumpster.Sfte Work Permlt for ail neVu projects:.Aif commerclai requirements.must meei camplfance
SIGNPERMIT AttacFi"(2)sets�ofEnglneered-Plans..,�_ --�-� � �. � � �
'"*'PROPERfiY SURVEY r�quired far att_M1tEW canstructlon. ._ `
Dlrectlons: , .. •� � � „ '
Fili out apptica8an compteteiy.
Uwrter 8�Contractac slgn back af appllcatlon,aatarized �
I� If over S250q,a Notice of Gommencement!s requlred. (AIC upgradss over�T50Q) ,
'" Agent(for the contractor)or Powei of Attortiey(for�the bwner)woulii be someane with notarized letter from owner authoriz4ng same
OVER'TNE COUNTER PERMITTINQ:�w-•�{Eront�of Applica8on Only�• - �_.�- -<_ . _a�,_k. _ _ _
,.r...._..___.. �__ ..... _ ._ ... . .. _ur,
Reroafs tf shingtes'�� SeweFs��' ��~�.5ervice Upgratles.A%C Fenaes(Plat/Survey/Footage) �,;;��, , ' ;. _
_" 1 r .._ .. .,z.��t��..� ..- ' ,��. , � vsi �.:,i�i�:.�-� i Yi�..,�.����i;l..:.i�,�. � ., �
Drivewaya-Notove`r,Counte�'tfon`publicroatlways::needsROW z; .,._, ..'4:1�,��..'r,°;;;;., V{� _1: �_�
,,. ., . . - , . .��,. . '1; ;:, ,. ,, „ .. - .,.,.-�,..,:.� !;
- �. _ :. .,:.� .....::.. . .. : n =._ .: ,_ �, .-.w, :: _ -:,:�,...-;_....-t:. -_ ,
� ,-.t.. �,::' �_�.
NOYICE OF DEED RESTRICTIONS: The undersigned,undergtands°=th�t:thi�:p�rmif.may:be,subject:to„"deed"restrictions" __
which may:be=more.rest(r.Ictive=th���.Countji'°r+egrilat(ons:-��The under'slgned��ssumes'respfinsitillity�for�compilance�witFi""any' " " "
appHcable deed restricttons. - _ � � _ , � .-� . -- - -� -•
IJNLICENSED �CONTRACTORS AND �CONTR�►CTOR RESPONSIBILITIES: If=the��owner=has�-�hired`:a"aontcactor or
contractors to undertake work, tFrey may�be�cequired�to:�be..11censed�in_accordance.with,state.and.local;.tegulations:-�if=the-• �`� �"�'
contractor (s-not�I(censed as� required:tiy law� both�the owner and-conUactor�may��be�cited�for�a�misdemeanor violatlon
under state law. If the owner or Intended,>;contraGtor;,are;uncertaln as to wrhat Ilcensing.,requlreRnents',may-•apply'�`for:tFie'� � �
intended uvorli, they are-advised=to boritacf the Pasco County Bulldtng:�lnspection b(vislon-Ltcenstng Section at 727-847-
-- - _ _-.-
8009. Furttiermore, If the owner'fias hlred�a cont�acfo��o�contractors� he ts advised to have ;the contractor(s),sign , ,,,,, � ,
portlo�s of the °contrector Block° of.this_applicatlon.foc,which they wlll.be.tesp.onsible...-If:-you;:as:#he,owne�'slgn�as`tlie`�
coM�actor, that inay be an indication that'iie=ls not:properly licensed and�is not entltled to permitting privlleges In Pasco
County. . ,. , _ , . _ ., ' . _ ... . .. _ _,,. w;. - �.
TRANSPORTATION.=IMPACTIUTILITIES�IMPAC'1�ANb�RESOU1tCE RECOVERY�FEES: T�he undersigned"understands
that Transportatfon Impact Feas�and.Recourse Recovery:Fees may.apply.#o�the_constructton of new.buildtngs,=
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PATENT#6634154 8�OT}-lER PATEhlT PEND1Nf
' page 1
OWER TE�Hi+tO#.QGiES,1tdC. - re�risioa 6!Q7
FLORIDAli�STALt.AT1UN IA13'fRUC'fi0N5 FOR THE
t�O,D�L,,,1101"�'S�RIES ALL STEEL FO�j�pA'[jQ�Y�,EM
MOpEI.7'{Q1"Y"(STEFS 1-15)
' LOtfGlTUD1WAL�iVL�:FOLtOW STEP3 !-9
� FQR At3�Rl,YG LA'T�P�,4L�4RFd;Follasar SGeps 90-1�
FOR COAICR:�i'�6�PPUCA'tfOPdS:Fotlo:�Sg�ps 16-�9
��tr�as s��.+� J�lGINEERS S7A�*,,.'�
'i.S�'EClAL CiRCt7t�STANCES: !P tf�e follo��ing condiuot�s ac�r-STOP! Contact Qliver Technolc�gies at 7-8Qfl-284-7437:
a) Pier height er.c,��ds 48" b} Length af home exceeds 7B'c)i�ao�eaves excsed '€6°d}Sfdewali height exceed 96'
e�Location is within 1500 feet of caast
t��p�t�n'rlc�hl QF GE20UF��PA[d
2. €��ave�veeds and debria in an approximate two�foot square to expose firm saif for each gxound pan (Cj,
3. Place groun�t pan(C)direct(y below ct�assis I-beam.Press ar drnre pan flrmty iMa soit untit 9ush vuith or beto�v saii.
SPECtAL t�0'T�:The longitudinat"V°brace sysfem serves as a p�er under tfie home and shoutd be Icaded as any
other pier. It is recocnmended that aifec leveling piers,and one-third inc,h('t/3�}before hom�is io�rered comptetely on
t�p6ars, comptet�st��s 4�,raugh 8 bsla�then rema��$jac�c.s.
��.�.Tf�����i�d c��t�Q�f�f e��'�1�8,4.E."1!" Ba'��.CE SY�ST�
P10TE: WfiEfd lfdSTALLIhiG THc !.Olf1GtTTlDlMAL SYSTEt+9�, A�EP�iEU{U414 OF 2 SYSTEMS F�R FLOOR SECTtG7d I8 REQUfREO.SCz4L TEST
PR08E SHOt1L{)8E USEd TO AET�R(�6H�C4R€2EGT TYP�QF,431CHfl�FElt,SDll.C1�,�3FlC�TiOt�.1F PR�B�i�Si'RE/;�igd�aS 6.���iWE�e+I
478 8.2?S A 5 FODT AhtCi-If3R F�t3ST�E USEl3.IF PR08E T�ST R�ADiT�tGS AR�B�TYJEEi�278 8�350 A 4 EOOT�,3dGtiG�Q N,AY BE l,fSEB,iJS�
GRO43P�D At11CtiORS YdiTfi DEAGONA!TlES AtQD STASitlZER PL.ATE3 EYERY 5'�}".VERTICAL 71ES RRE ALSO REQUIRED ON HOh7E$SUPPI.{EO
' WiTH WERTlCA1.'i'GE CON�dECTtGM POt�1TS PER FLQRtDA REG. .
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4.Setect the correct squase tc,be brace(E}length for set-up(gier)height at suppflrt iocatiQn.("t'he 18"tu�,e is always
u�,e�a�t�te bat�o?�t par�af�;e tongi,�dirsat arm). t�cte: Ei�er i�sbe can bs used by itsetf,cut and drilted to(angth as long as a
4��o �6 ds�ree ar��Ee is ma:r�taiaed.
PtER Y.EfGH3 1.25°F.OJUSTABl.E 1.50"AC?,1USTA3L�
(/�pp�ox.45 dsgreas P�i«x.) Tube Lengtkt Tube�.�nrtth
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5. instatf(2)af tne 1.50"square tubes(E {98"tube})into ths"t!"bracksf(J).`snsert�rria�e bo!t a�d teav�st�t la�sa tcr�na!
adj�stmerit.
6. ����e t aua�►c�nnec:ar(�=)ioosety on tlze bo�am Ranye of�e i-beacn.
7. S�iva th�sefec�l 4.25"'��be(E)inta a 1.5�°tube(E)an�aY�acY�to 1-beam ecnnecir,rs(F�and faslen iaasefy�vith bolt and nut.
$. Repeat steps 6�sough 7 to create the"V'pattem of tne square tubss loosety in p1acP.The ar�gle is not to er.eeed 45
degres and na#beicvr 40 degrees.
9,f��er a{f t�olts are tighteneti,secure 1.2a and R.50°tuhes usin�fo�r(4)1/T"-14 x 3J�°self-tapg,ng scre��s in pre-drilie�hof�s.
� �`�����'B 8�t'� c3F�A,�'�g=.��S�tJP13�G i'RO���SVER��,A€��4 SY��R4
7Fi���C3�3�1.4'��59 "`J";LC?:"�Gii llk3il4J•.��.I.�:�PJ�E F'�?.s�TECTiOPt}��J�#�iAl'ES�TFiE E�EcCD FOR i40�ST''aT�".B'a�a..�Ef�S PLATCS F4 FP�''.�.C�iC�CiFS.
P!�'f'�:T�i�t6��4F'i#i{S SYSTE€�4 F'�.�LiU�?.ES 10ERT3CAL Tf..�,S Si'f4{:�D AT 5'�".
FUt�R FbQT{�i')G�?C3Ut�D AttiGi-�OR���Y B�t�S�r�FXCEP'C�b"e'.�i��'i':-1�e�Of1����r`�ldtSrhGTtJ�EFt S£�EGt��ES Gi�rEREPa7;
10. Install remaining vertical�ie-dovyn straps and 4'ground anchors per hom8 rr�an�-faci�:eer's insu�acc:ions.t�OT�:Centerline
anchors t�be sizeci ac�ording to soii forG�e c*sntfitian.�y�a��#acturer's;��cifi;,aUar►s for sidev�°�!1 anchor lo�s in excess af
4,O�fl Ibs.requ'sre a 5'anchor per Fto�ida Coda.
i't.A4bTE:Each system is required to ha��e a fsarr�e t�s ancS$tat�iiizer aitached at eacn iater�k arm stabi4i7sr�a loc.ai'son.This frame tie &
stabil'�zer plate needs to be located within t8`from ofi center ground pan.
12, Select the cc,rrect squars tvbe bracs(H}4ength for set up latsra4�ransverss at support toca�.ion.The fe��gths coms in ei`�hsr 6�"
or 72"lengths. (VJith the 1.5J°tube as the bottom tube,and the i.25"tube as the inser�Gd tube.)
13. lns:alt ti�e 1.50 transverse brace(H)ta fF►s ground pan cannector(Q�w+th balt and nu+
14.Siide 1.25"transvesse brace tint�ti'�a 4.5�"�race and attach to adjace�t t-�eam ccnneoEor {d }vrfit�boii and s�u�
i 5. Secure 1.50"transverse arm to 9.25"transaerse artr;usin fo�r 4 '(!4"-'t4 x 3!4a s�tf-ta in screws[n��e-dsik4ed holEs.
`'``�•• (3LI�'EFt�'�Gt-DP�L4LQGIES, 6?�C. TeSeafione:931-?9E-a555
� � 't-fiD0-28�-?437 Fax:93�-796-8811
'��- l4:fiV.A!R�eR��r,e!o�;as.cw-t
�
� , �age 2
�^��4{..�,�no�_�}�?it�t'a'�Qi�GR�E iti1NPZ�,i2(,gt30�"�R >•:<-'. , .. s'cr'isioa fb'07
9S. A cx�nc�ie nsriner,€ooter or s}ab may kie used l,z p�ace of tf►e�e�i ground pan. �
a� f'iie cancr�te st�al�be minirr��rn 25QCi psi m:x
�) A�rt�'ete rs.u:ne�tnay be e�;her 6o:sgi�ad'sc3ai car transverse,and rr;ust!�e a�rtinirsZum of 8°dsep with a mir�imurn wid�of 96 inc��es
Eong;tti'�na�y c�r 48'tr.chEs'Ja�s�erse to aiiow proper c�istance bet�:een tfae co�►cre�E�lt and tfie edna a##�e cQnere`�e(see belowj.
c)� Faobers must have rrfinfit�um s�trrFaca area of 441 sq.in,(i.e.21°square),and cnust be a minimum o€8'deep.
d) 6f a fic�it slab is used,#he depth must b�a A�"cninimum.
Spe�i�i inspeciian of�he systetn bra.k$#in�#�ltatio�is not re�uire�.. �'aoter must a}1o����er at le�t 4�frosn th�«�,��e#e batt#o thn�iyo
Of the cos�c:�ete. '
h�0'��:�e batt�r►a#a��!�4�nc�s,pads,s3abs and run»s�s mtsst b��ss tmcal�ur�sdk�a�.
LQhiGt'Nt3iPdAl.:(i�4ode19't01 L��V"j
47, 1�Jhen usin�Part�910'(-IN��A�wetse�j, simpiy instalt the bracScet in runnerJfoo;er�R GWhen ins aiting,in c�tre�aoncrete use Part#
1d1-D-CPCA tdryse#l.The'l9p1 (dryset)GA bracket is attached to the concrete using(2}518"x3"cancrete wedge bolts(Simpson part#
S4623DOH 5/8"X 3"or Pow�rs equivatent).Place the CA btacket in desired tocation. tJark bo#t hote txations,tf�en using a 5/8"dfartieter
masvnry bif,driff a hote to a minimum de��of 3". �t7�fce su;�atl+dust and concrete is�3�5�aut o�the holes.Place�v�gs kxi#.s ir�o ctr)Ued
ha1�s,ftten place 9'i 01 {dry setj CA bracket o7to va�daa balts ahd start vredge ba4t nuts. Take a hamcner and tighdy drlve tzse wedge baLs
dcv�:�by h�ttfrtg th�nut(making sure not ta hit the top af#hreads on ba3t).The sle�ve of e.r�ncrsf�vr�dgA bolt�se�s to be at or belc>�v the t�
of coricrete.Compfete by fightenin�ncats.
L.A'�ftpsL:(N�ocfef�909'fC"V")
1 S, For+r�et set(part#91�9 V'd-TAG�)installation simply instail the anchor boit inio ruznerlfooter For dry set ins3�ilafion(gart�i1Q2-0-T�CA)
mark bo1#hote 4�ca��ns,tFtert using a 5!S'diam.masorxy t�it,da't1 a hoie to a m'snim:�m 8epth o#3". �Jla�:e sure a1i dust and concxete is
b}ovrn out of tiis hole,Placa wed�bo;ts{Simpson part#5462300H 5/8'X 3'or Pe�ers eyvivalent)ir�ta{D}cQncrete dry transverse
cc�r�nectos and irfta drilled hofe.If rseeded,taks a hammer and tightfy drive the rrdedge bo1�dovrrt by hit`.ing tfze nut(ma�ing sur8 not to hit
+he tQp o#threads an bott),tlaen r�emave the r�u�The sl�gve af can�e�e Kredgg�ft needs�q be at c�,ba�oLy t,�,��o,�at c:o�ete
f9.V'dhen us'sng pa�##'[109 CV�N(wetset)ar'[10i C1/D(dryset),i�stali per steps 17&�f8.
�(3�E3S:
'i. LEI�IGTI-t OF HUUSE !S THE ACTUA�BOX SIZE
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ALL, I�V�DTHS; �flD LEi�1GTHS 41(�F2 52'TO 8�'
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arz�wa ruy t�u_ce�'%�e� - , � - � ro-risio�C�t�7
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io�4�`ts 2xceptv�ers -
h�me men�fac�uers s��-
f��fOtis tCi sis��ve1!st7'eps / � 4
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ara ln�xce�s af 4,�9(bs. i- Tratssverse asm I-t�am �'i i t�ri flr ���9
- '�r�sE E�.ie;ts requ�e a 5 c�usecW;. .y . —�
sa�at?a.;Per Fiorl3a Coste. / �H- Transverse arm
/ Top(1.25')
��(�•�') C=GROUi�D PAN
i 13=GROU�ID PAN CONi�ECTflFt
o:�rocm� �"4 ��t�ca��in � - tt 6s�CKETS TR'hi�1SVEr'iS�
Pan � cxinnectors E=TELESCAPit3G V 8RACE
�a���`` q �� TlfB�RSSEMSLY W/1,5$OT
connectars �-g���p� T'OM i'UB�AtdD t.25 TUBE
W � / V araci:et lNSERT
fi="V" BRAGE 1-BEAM COf�NEG
TORS ASSEMBLY
�-w'arace Tut� � H=TEt.�SCOPlHG TFtAI3SVERSE
� Top{1.25'� ARM ASSEM,BLY
scuom (�.5°) I=�RfW8VE4SE ARi�!!1-R�At,A
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am r-;cramp
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DISCLOSUR.� STATEMENT FOR OWNRR
CITY OF ZEPHYRHILLS SIIILDING DEPARTMENT
I, have read and fully understand and
agree to the provisions of this iastrument. '
The undersigaed states aad affirms that he or she is desirous of constructiag,
reaovating, adding to or reroofiag his or her own domicile, that he or she '
actually occupies, or will occupy by said domicile, aad same is aot for
reat, lease or sale. That he or she shall comply with the followiag conditions:
1. That the owner aad he or she alone shall act as the builder for all phases of
coastruction.
2. That the owner will comply with all provisions of the City of Zephyrhills
ordinances and codes pertiaeat to the building.
3. That ia the event various phases of coastruction are subcontracted, he will
eagage only properly liceased subcoatractors and will persoaally supervise
such work.
4. That in the event the Building Inspector shall require correctioas to be made,
the owner will assume full responsibility to insure they are made, and upon
completion will call for a reinspectioa before proceediag with the building.
5. That the owner shall assume full respoasibility for the constructioa and will
not expect supervision of his work from the City of Zephyxhills Building
Departmeat.
6. That prior to final iaspection any additional fees, iacludiag reinspectioa
fees, must be paid ia full. A written request from this office shall
coastitute an official aotice to pay additional fees.
7. That the owner shall comply with all City, State and Federal laws in regard to
social security, workman's compensation, lien laws, etc. , where applicable.
8. That the owaer shall comply with all the safety codes issued by the Florida
Iadustrial Commission.
9. State law requires construction to be done by liceased coatractors. You have
applied for a permit under an exemption to that law. The exemption allows
you, as the owaer of your property, to act as your own coatractor with certain
restrictioas even though you do aot have a license. You must provide direct
oasite supervisioa of the coastructioa yourself. You may build or improve a
one-family or two-family residence or a farm outbuilding. You may also build
or improve a commercial buildiag, provided your costs do not exceed $75,000.
The building or residence must be for your own use or occupaacy. It may not
be built or subatantially improved for sale or lease. If you sell or lease a
building you have built or substantially improved yourself within 1 year after
the coastructioa is complete, the law will presume that you built or
substaatially improved if for sale or lease, which is a violation of this
exemption. You may aot hire an unliceased persoa to act as your contractor or
to supervise people working on your buildiag. It is your respoasibility to
make sure that people employed by you have liceases required by state law and
by county or muuicipal licensing ordinaaces. You may aot delegate the
reaponsibility for supervising work to a licensed coatractor who is aot
liceused to perform the work beiag done. Aay persoa working oa your building
who is aot licensed must work under your direct supervision aad must be
employed by you, which means that you must deduct F.I.C.A. and withholdiag tax
and provide workers' compensation for that employee, all as prescribed by law.
Your constructioa must comply with all applicable laws, ordinaaces, building
codes, and zoniag regulations.
OWNER'S SIGNATURE � ^ DATE ��� � `��
ADDRESS 5 T /
PHONE 3 S 3
WITNESS PERMIT #
Detail by Entity Name Page 1 of 2
Florida Deoartment of State DIVISION OF CORPORATIONS I
., -1{ , !
�; � 'J1`l'��J':t'✓I
���l�l����'�'���J„'�1���°���\1'.['i[J:i:'�:�
.�s�..�:� (u,r�J,�=i�l!_;f;,ju:7rirl;lri/�,�'.;'?;,.—;rf:'
Department of State / Division of Coroorations / Search Records / Detail Bv Document Number/
Detail by Entity 6Vame
Florida Limited Liability Company
CREST OAK,LLC
Filina Information
Document Number L16000228293
FEI/EIN Number 81-4850323
Date Filed 12/19/2016
Effective Date 01/02/2017
State FL
Status ACTIVE
Princiqal Address
38642 EVELYN LN
ZEPHYRHILLS, FL 33542
Mailinq Address
P.O.753
ZEPHYHILLS, FL 33539
Reqistered Aqent Name&Address
WILSON,JAMES M
38642 EVELYN LN
ZEPHYRHILLS, FL 33542
Authorized Person(s)Detail
Name&Address
Title MGR
WILSON,JAMES M
38642 EVELYN LN
ZEPHYRHILLS, FL 33542
Annual Reports
No Annual Reports Filed
Document Imaqes
12/19/2016--Florida Limited Liabilitv View image in PDF format
http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 11/7/2017
i � � �
I
� Electronic Articles of Organization FjLED 8 00 AM
For � - December 19, 2016
Florida Limited Liability Company sec. Of State .
tchang
Article I
The name of the Limited Liability Company is:
CREST OAK,LLC
Article II
The street address of the principal office of the Limited Liability Company is:
38642 EVELYN LN
ZEPHYRHILLS, FL. US 33542
The mailing address of the Limited Liability Company is:
P.O. 753
ZEPHYHILLS, FL. US 33539
� Article III
Other provisions, if any: _ ,
RESIDENTIAL RENTALS.
Article IV
The name and Florida street address of e e '
th r gistered agent is.
JAMES M WILSON
' 38642 EVELYN LN
ZEPHYRHILLS, FL. 33542
Havin been named as re istered a ent and to acce t service of roces
s for the above sta.ted hmrted
liabilit�y company at the place designated in this cert ficate, I hereby accept the appointment as registered
agent and agree to act in this capacrty. I further agree to comply wrth the provisions of all statutes
relatin�to the proper and complete performance of my duties, and I am familiar with and accept the
obligahons of my position as registered agent.
Registered Agent Signature: JAMES MARION WILSON
Article V L16000228293
The name and address of erson s authorized to mana e LLC: FILED 8:00 AM
p � � g December 19, 2016
Title: MGR Sec. Of State
JAMES M WILSON , tchang
38642 EVELYN LN
ZEPHYRHILLS, FL. 33542
Article VI
The effective date for this Limited Liability Company shall be:
' O 1/02/2017
Signature of inember or an authorized representative
Electronic Signature: JAMES MARION WILSON
� I am the member or authorized representative submitting these Articles of Organization and affirm that the
' facts stated herein are irue. I am aware that false infortnation submitted in a document to the De�artrnent
of State constitutes a third degree felony as provided for in s.817.155, F.S. I understand the requ�rement to
file an annual report between January 1 st and May 1 st in the calendar year following formation of the LLC
and every year thereafter to tnaintain"active" status.
aa�iii��ti«��if��i���«�i��ii��������ii����������ii����i�����
2017�.5256�
� �t��i �R� .
P�ared by and_rctiur.to: „`+,4 �� ,4cp�:1897488 lt�c: 18.�0 . .
Jesnic Gt���i�c _--�--�—�` DS: 0.70 YT: 0.00
Premiom'X'ftae,�nc. ! �� � �9/2812017 E. M. , Dpty Gler�k
14150 6t�Stxect ,
� dade Cityf R1,.33523
352-567-5658 +Ru�� s,0'J�E;L:Ph D pA$�0 �LERK t� �pM�+�'ROL�CR
�ileNvm6er= 17-tt3.7 09,+28l20�7 62:� m 1 of 2q
�onsider�tion-None OR BK ��1� F� '�'�.1�'"�`1
fSpacc Atmve 77�ig�,ine PoC Recordi�g Qatat ",
�Oxr�CtlV�
'�axxa�.t� D�ed
This W�rra�ty �3e�d made this `f� de.y o,F ,2Qy7 hetvuee�a Jak��a 1Pau� Ja�nes a�.a Trustee of the
�,at►d Tcust No. ?2167551G �uhose past oi�ae address is Pos C!l�ice 8ox 669,�eph�*rhills,I'L 33539-t3669,grarct�ar,and
Cirest O�Ct,LLC,a Flarida tirnitcd 1�Ability cotn�any whose ppst offce ac4dtess is Post Office Boa 753,Zephyrhills,FL
33539,8ran:cec:�
(W!t¢nCvcr u�cd hcrcia thc tcym.a "grs�nt�r" and "gt�u�tcc" includo a11 tha partic.a m thi�inswmenL Tnd thC hcirs,1�gal represantativcs,and assigns of
iodividat�ls,Itnd(hc succasors and srtaigns p�f cprppttttl0t15,ttusts�utd hv.ytcGw) .
�atluesseth,that said grantar,fvx and Rn'cansidcration of the sum of TEN l.�►,ND NOJ.l00 DOLLA,RS (�].0.00)and athcr
gflod and vafuab�e cons�derations t�said gramor�in hand paid 6y ssid gtantee,thc rec�ipt whereofis llere{�y acknowledged,
has gran#ed, bargained, and Sbid to the said �rantee, and glruntrcc's hcirs and assigns forever,#he fallowin�described land,
s�tuate,lping as►d being in Pasc�Caunty,Flocida to-wit:
SEG(1V AT '.["FZ� NOR�TiEAST CORNER OI� '1'RA,C'�'30, SECTiON 2,TOWNSHIP 2G SOUTA,
RANGE 21 �+AS'� AS Z�� ��++.Il�TE IS NU�BERED AND S�t3V4'1�t 4N T�IE 1VIAp CtR Pi.�iT OF
`�E ZE�HYRHILLS CO�ONY C01V�P,c�Nli` LANDS AS THE SAML� AS RECpRXM�b �N '�
�'U$L�C RECORDS OF PASCn COUiY'�'Y,�'LURIDA; THENCE`'t'FST Z4�1�'�E'�,SUEJ'X'�i kb0
�'��'�', THENCE EAST 2E�0 �'�E'X', 'THENCE N4RTR i 00 F�ET, TO TTrX� �OIN�' O�
��GiNNIN�.
.�'�x`cel xctentiticatian Number:42 2+Cr�I-q010-03000-00�0
THIS TS A C+p�EC't'I.VE WARRANTY t)�ET,��Qx2,RECTXNG THE NAME OF TNE GRA,NTE�
FROM OAK CRF.�'�', �,,�C TO CRE5T OAEC, LLC, a,S R��'�,ECTED IN THAT CERTAIN
WARRANTY DE�D �'�L��? �+flR REC4RD FE�#RIJARY 2$, x�I�.7 �iY QF�C�AL RECt)RDS
�OOk.9502,l'AGES 312-3X3,OF'���UBLiC RECORDS OF PASGU C��IN'X''Sl,�UR.IDA.
'3'q�;eE�e�ti'vit�at1 thc tcnements,hereditaments an$appurtonances t}ier�to belonging or in anywise appettaining.
To I�ve a�d to�Old,thc same in Fea simple fcrrevex. '
And the grantar t�erehy cave�attts wich said grantee that the�rantor is lawfiul�y seizer3 t�f sait3 tand in£ec simple;that t�u
gr�tttor has good right and tawl"u�authority to sell and convey said land;that th.c granwr facrcby fully wasrants the title to:said
land and wiIl defend the sat'ne against thc lawful claims of a11 persons w�tirqsopvct': attd tkat said Iat�d is fr4e of'ail
i encumbrasices`,except t.�3ces a�it� sp�ci�l asscsszneists accruing su�sgsquent t,�Aerteatubetr 31,2016, urriing andior•restrictions
' imposcd 'by gnvemmental autho.rity, �utd ease�nenrs,rostrictions,and re5ervatiqns of record.if.any, howcvar.this rcferencr
chati n�ot serv�to zcimposc ttze same.
DoublaTlra�g°D
oR sK ��1�0 pG 13�3
z �f �
�xt�YItIIe58�hCt'eq�,granLor has he�unto set grantor's hsnd and seal tl�e dAy and ycat first above written. �
Signed,sealad and delivered in ourpre.eence:
� ' �
Wifiess Name• ���
J Jqnecs„Trustcc f
��--� � �a��
Witriess Name• _CQ.o r\,�H r S .�o���S
State of Florida
County of �'q�c�
�� ,� J +
The fpregoin�instrument v��aS acknowledged befiore me this�day of%/'� � �OI7 by Jahn Jones,who�]is
persona]ly kr.town oi�J has producecl A�lorida driver's license A9 idontifieatiQn.
�
[Notary Sea1] 'ot&ry ubl.ic,State of Flprida �
Print¢d Name:��i��'�/ c� ���/i�d
�K.ar "'"'
��`�' A�G•�YDl'40 MyCommissionExpires:
,��* A1Y C01�,l19SION 1 FF 105� --- �_....—
�2o��.a� sn�aaear�n e�tl�le�f►2i,20ta
D� ehry 8ervket
Iirerraxry Deed,Pa�,e 2 DOubIBT�Ii#9�
cnn�vfe acva_ suQ! R�T� I ��I ����� � � �� # � 1066588 '�
I S � 2I 5319 ������li��� �� m
987174583
-. I. ._. I_._.___.. STATE OF�LOR�,I� e6 �sa9sq
�auoiT�l • • � S8A17824
; A.PPLICATION FpR Y�HICLE/VESSEL ;
, • ---.....__.... I CERTI�'1CATE Ok"�'�LE �• ...-
. . .._.........__..------. _...._..._._ ... .
TITLE NUMBER VEHICLElVE53EL IDENTIFiCATION* 1fR,MA}(C MAKE or BODY y�ryICLE COL6R 4YTILENG7'H GVW(LOC
� MANUFACTURER TfPE
---• .._..._ i . .. __ .. .. ,__ i
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iI 21396443 I K8225PJ3....._.,...._.._ ._. � ]982 i f SEAB . .... I r•TS �UN.K _ � �7�-----.--.....,I I__� ,
nATE OF ISSUE TRWre3 �H t C I.E U S E N��� P R O P U l,5�4 N F U E I V E 8 8 E L WA TER F�NUMBER A U T F f
� MQ. DAY YEAR COdE M/{7�� 7ypE DESTRUC7101+1
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'•. 09 ;29 I 17 � ��fi_ i -pR���.�8....� . . .. _..._le���---.f _: �: �� I _...._.....�-.---_l_-..--.--- �-------..-. �--.--...
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BIR7WDA7E RESIDENT CNTY
' S�X MO, DAY YEAR Y N ALIEN REs�
ADP�IcenUOwnAra Neme&Addroae ,
� ro sax�s�Lr_c i� -��-�-�--� ��_.�__._I... ! I Z8._�
� ZE�HXRT�IL�.S,FL 33534-0753 iat OWNER FUD�OR zna owni��roua oR
; F.E.I.D.� uNn�
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' 814850323-01 I I � j
VOLUNTARY GONTRIBUT10N5
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! AGENCY nn,E FEE 9ALE8 TAX GRANb TOTP1�
� FEE �
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� 4.25 73.50 � 0.00 77 75 I �
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PREv STATE. DATEACQUIRED 'NEW USE9 ODOMEiERlVES&ELMANUfAC7UftEt2 OPOMETER I
� DECLAkATION I
� CER'fIFIGAT70N i
�z, os�i4aoi� xx � .
�_..._...._._... ---.... . .. ...---=---- ----�---._.... .. . ............._ -�-�------- ----_.__---!
II •LILN INFQRMATION DAT�OF LIEN �CEiVED Dn7e FEID C OR FLJ DLdINQ SD�AND DA�OF B�RTH DMV ACC�)UNTl�
NAME OF FIRST LI�NHOLD�R; ;
_ .... I
�AODRESS SALWAOETYPE i
I
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'S��LBR IIYFORMATION
NAME OF SECLER,FLOliIDA DEALER,OR OTHER PR�VIpUS QWNER '
AODRESS I
, I
;DERLER LICEN9E NO. ---- ------._.._.—_.�.---.... _. . .
� •CONSUMER OR BALES TAX E%EMPTiON 9�
�.. ._._.... .. . • • -� ---•---�..—.-- ---•-- -----------•—•—••------.._....._ ....._....• _-•-• •_ I
SALES TAX AND US.E REPORT INDICA7ETCRAIPURCHASE PRICE,INCLUOINGANY & �
UNPAItl BAtANCE OUE SELLER,BANIt OR 07HER9
I TRAIQ3F&R OF TITL� ❑ L��'RC�ISER FTOLD$ VALID •----•. ...__.__.._...._
I3 EREMPT FROM EREMPTI82Q CERTIFZCATE INDICATE$ALES ORUSETAI(DUE/AS PROVIDED e1 CNAPTER S O.00
FLORIDA SAL�S OIt ❑ �'3."HICLE / V�551�I� WILL HE 2�2•FLORIDASTATUT�S
VSF, TA}[ FOR T8E 4SED EXCLQBIVES�Y FOA &ENTAE, _•-••--.... ....-..._.....
�REA50N(S) G1E�Ck'�A I� 8��� �TiI�R ❑ SES�LTNCt pRTCE l�RZFTED
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+APk�LICA�iT CER'�IFSCA'1'IQN
IfYVE NEHE6T CEKTIF7�TIAT THE VEHICLENEHB�L TO 6E 7RLE0 YdILL NOT BE OPEHfi7EG UP0117ME PUBWC MIOMWAYOIWAYERWAY�OP 1MIS diA1'�
1 ClRTI�Y THAT THE CBhTIRICAIE OP TITLE 19 LOET 6R�eE7RWED.
1 CERTIFI'TWATTNIB MbTOR v6NIC7.EKE9961.wM qSPGAnS�FW uaoN DEFltU1.T aF TNE I.IFN 1�7R�MDIr PNn w NOW�[�t FT/paaASsNrar{
I IiwE n�eT cER71F'P YMNT IAM6I.AWR47LLY OWN 7H�ABGYQ De�GR1tA0 Y9NICL6/MgBSHL,AND MAKH APPWCAtiON fGR TIi'L�IP LISN!0 B81NB RQCORDaD NOiIC9 ID HER�mY OIVeN THA7 TNRk4 IE RN
F�aanN�WR177RN I.IAN�Ner�uMRNT��.v�No r►���qH�e�,q�vqen�4 pqaeR�paP As��hran Mel.p DY I.�pNRO�p�ah4Ww pDavR�Uwq pt1RTNQRAmlt4q YG OR�allo 7HQ TITI.�AflAINaT ALL Ct,q�M�, � �
urueqR p9NhLYiRe eF PR�uav,r oAc4ns��{�T�MIWKA91w iN8 FnaSvo�No pxuMBNs nNa TWtt7X6 pncY1+QtnTR�n Ik RNGs i►tu�.
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SlflnaRurn af pppllcan�l0��r,ar Slpnature otApplicenVCo•Oumer
,H9MV 82041 REVISEI�02106 SCAN CaDF. MVT
._.�..----•--------•----•--------------•-•._......... ......,_.__._..... . . . .
1�N6ERSTAND THAT MY DRIVER LICFNSEAND REOISTRATION5INILL BE SUSP�NOED I�AMEpIpT��Y IF THE INSURER DENIES
THE INSURANCE INFORMATIOfV 5UBMITTED FQR TNIS REGISTRATION.
CNTYs AG11e_ SUBe_ RPT� ���I ��4��������'I �I� I T+� �06458C> �
28 i 21 5319 � �1r
-•••--..�•--...r. � 989I73526
� STATE OF FLO�IDA I� 7644�50
��R� APPLICATION FOR V.EH1C�,�IVESSEL s� 58417680
� I.. ....., . ' � ,
' CERTlFICATE QF T�'��E -�---� -�--._._....__._..__ .
TITI.E NUMBER vEFtICL�fV�gSEL IDET1TIfICATION o A YR.Mn1(E �E'� BODY VEHICLE COLOR will�NGTH GYwn.00
MANUFAC7t,1RER TYPE �
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; 21396442 ;K822SFA � �98z i 1"'
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I OA7EOFISSUE TRATdS v�HIG1.EU8E HW� PROPULSION F�iEL ��E� WRfER FLNUMBER '�TW
' ; M0. OAY YEAIR COD� MqTERIAL TYPE aESTlZUCTION
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eiRrrromrE R�SID�N7 ��
SEX M0. nAY YEAR Y N ALIEN RES.i I
AppflcanVOwnet'eNemeBAetlress ___... ... ,
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V6LUNTARY COMRI6117�pNS
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A�ENCY 71tLEF�E 3RLE3TA7C GRANDTOTAI, i
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°: i . . ...........__..__._ �.25 '• �_ 73.50 I__ 35.001 1.....---_ 112,75� �
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i Act.�on R�q��Qtad e TRA�NSFFR T'ITI,E a��►�ads: �
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PREY.STATE DATE ACQIJIRED N�yV . .U8ED . .ODOMETER/VE33EL MANUFACTURER OQOMB 1'Eli.--..Y. I
� OECLAkA7TON
ce�n�cnnoN
FL 49/192017 . � �
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rLIEN iN�'ORMAT(Q�1 DATE OF LIEN R�C�NEO DATE FE7O 0 OR FL/DLANQ S�X1Wp�A'�OF F3�RTW DMV ACCAUNT�
!I II �NAM�OF FIRSTI,I�NHp�DFR;
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I IAbDRES3 3ALVAOETYPE
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�SEJ�LER iNFORM�1,T10N . �
NAME OF SELLER,KLORIDAbEALER,OR oTFiER PFt�V10US OWNER
;AD�RESS
DEAIERtICEN5EN0� •_--••-•-..... �_.......__.._ .... __. _._._. .. . .._.. _. .
ICONSUMER OR SALES TAX EXEMPTION!
... . . _... _....... .. ._.. . .... ._....._.__.... ... i . ........ ..__. . . ..
� SALES TAX AND USE REPORT INdICATEI'�TALPURCHA8E PRICE,iNCLU0INOANY $ 500.00
UNPAIO 6AfANCE DUE SELLER,BRNK df!07H�R3
.TEiA1QSFER OE TITLT C� PIIRCH�B�R FiOLDS VAirIa .. . . ..
�S EXEMPT SROM EXEMPTI0�7 CERTIFICATE INDICATESALESORUSETPJCDUEA3PROVIbED6YCFiAPTER $ 3S.00
�zo�xp,A. s�as oz� O v��tzcz,� / v�ss�z� �zz��. z� a�z,F�.oRio,asran.rr�s ----•--------..
IISE TAB FOR TEE IIBED $%CZdJBIVES+Y FOR RENTAL
REA50N(S) CEiEC�D ❑ �TiiSli ❑ BELS�IN6 PRSCE p�RIFT�D
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APPLICIlNT C�'�i�A'xb'xCl#'J.'x0�7
IIWq 114REEY ElRTIrI(TNAT TFIC VCNICLENCBEELTO BE'fiTLEO WILL NOT 9L�PBiA7E0 UPON Tt1E PU9LIC HIOMYYhYHMfqTEFiWqt9 OF'R119 BiATE.
I�f C�RSIFY TMAT SNE CeRTIDICAT�Cp TITLE 13 LOST OR DAaTROY104 .
f cCttl7rY THAY THIS MOTC11 V[HI�1WlE�GL WA611l�06DlEElD U�ON ClJAULT C�TNE LIlJ1 INETRUMlHT AND Is NOW UG NfY POssESEION. I
�uwe N�erce�inas urvE uuyw��Yvwn ineaeove oee�aiaeo ve�ii��ervEoaeL,ano�e�t�P�tCATfON ROR TIfL9�IP LIEN W D�INO RECORPAD NOs�eE IR N4REOroryAN THRT TH��tR la AN
�exTa�rmo wairl'�tr LiQN IN87RUM9tiT INvo4VINo rHll�+eH��LAnr4arpl.pelseR��AoMevqpNe H4�.p pv upNHo�een eHowN aeev�uwe�uRTHeRnu�e m oeF�un THe nx�aoniNaTau cuuMa.
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� III�NER PEN/LLTIEB OF VERJIfRr 1 DQCLARQ THAT I HAYE REAO THE FOREDOIN9 DOCUMENT ANO TH0.T THE FACTB BTAT�fN ITAFlE TRUE
Stpnetute of AppllaqrrHpwna� Slp�ature ofAvpllcanUCo-Owner
H3NN820�1REVISEOOt/08 SCAr1CODE ]VjVI
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I UNDEFtS'I'AND THAT MY DRIVER LICENSE AND REGI37RAT10NS WILL 8E SUSPENDED iMMEDiATELY IF THE INSURER DENIES
THE�NSUFwNCE iNFORMATiaN suBMl'rT�p FOR THt3 REGISTRATION,
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City af Zephyrhills
BUILDING PLAN REVIEW CtJI��LMENTS
Contractox(Homeowner: �� I °��YJ�tf� ; �
Date�teceived: l G "r �� l
Site: �J ��� l� � ��
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Perniit Type: f���l�l G�-�P� �G�
Approved w/no comments:❑ Approved wlthe below comments: 1� Denied w/the below comments: ❑
`� "� � � a� t�� �� '"^ � � � �l �
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nis commen.t sheet shall be kept with the pemut and/ar plans.
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Ians Examiner ate tractor and/or Hameowner �
equired when comments are present)
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- NOTICE OF CONIlVIENCEMENT �
State of ��C�('�('`C'� Counry of ��l D -
THE UNDERSIGNED hereby gives notice that improvement will be made to certain reai properiy, _
and in accordance with Chapter 713, Florida Statutes, the following information is provided in
this Notice of Commencement:
1. Description of Propezty: Parcel No. ��-a LQ'o�� ' ��1 O " ���� ` ���
C�1�� li o �-�, S�- z�nl� 1 r h� (I� � {�( ��S� �
(Legal description of the p pert and street address if ava�lable)
2. General Description of Impzovement
�+�.�a � Y���� � �.zr�o T h C-k1 �
3. Owner Information: Name �P��- �"�� '1 L C� -
I � Address `� �Q��r. ►�� CitY � State�" �
Interest in Property: I IIIIII IIIII III�I IIIII IIIII II�II IIIII IIIII IIIII IIIII IIII IIII
Name of Fee Simple Titleholdez; 2017183836 ,
(If other than owner)
I Address City State
4. Contractor:Name ��P��t ��.i`� �`�
Address � �fl (� ►�St��e�_
, 5. Surety_Name
Address City State
Amount of Bond: $ Rcpt:1510556 Rec: 10.00 'I
DS: 0.00 IT: 0.00 �
6. Lender:Name `' " 11/20/2017 M. F. , Dpty Clerk
Address City State
7, Persons within the State of Florida designated hy Owner upon whom notices or other
documents may be served as provided by Section 713.13 (1}(a) (7),Florida Statutes:
Name
Address '� City State
- 8, In addition to himself, Owner desib ates
�� �N� o f to receive a copy of the Lienor's Notice as
'` �LL N� provided in Section 713.13 (1} (b),Florida Statutes.
�m��� 9. Expiration date of Notice of Commencement(the expiration date is 1 year from the date
=,z�� of recording unless a different date is specified.) pqULR S 0'NEIL,Ph D PRSGO GLERK & COMPTROLLER;
��X� ' 11/�ROB 017 11:28am i �oyf 1 q ,
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�6�� P� G��"T
;,��s���,,, Signature of Owner:
��`��....�� �
_����' � Sworn to and subs �b efore me this day of��� '20�
'��.���'I�
' 1*Iotary Public:
My Commission Expires: y �
PC93053048/A
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,,Q�`�-��� _ a� a�Cf�;�"�G!S= �t.��,1�,4,�OURITY OF 6��S�43
,���'�-'�"'� ,� '� � THISI��"fC1�;��RTIFYTHATTHEFOREGCJiNGISA
i�," ' ';���';���:,�y,,. m � TRUF ANi�C��hf1ECT CO!'Y OF THE DOCUMENT
°� '`"' ,�����;��'„ � ON FILE Gi:(?F PUBLIG RECORD IN THIS OFFICE
� . ���'s��°` ��` ��a '� VdITN�����''Y HAND AND OFF1IC-I,A�L SEAL THIS
�."��"�,� ���, _DAY Or I�V�Y�iY�LI� �--�
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� �j� ,��. „ ,<,�,,/ .' f 2
: �a�" �Ut� ,� �AULA NEIL, CLERK&CO?�iPTROLLER
�p$ ��� +���,°f'rJ @ � -
�� ����y� �����g� Y , DEPUTY CLERK
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