HomeMy WebLinkAbout22-4884City of Zephyrhills
5335 Eighth Street
Zephyrhills, FL 33542
BNR-004884-2022
Phone: (813) 780-0020
Fax: (813) 780-0021
Issue Date: 10/04/2022
Permit Type: UU111ding New (KesidentialC.
Name: LENNAR HOMES LLC-OWNER Permit Type: Building New (Residential)
Class of Work: Townhome
Address: 4600 W Cypress St 200
TAMPA, FL 33607
Phone: (813) 574-5700
CONSTRUCT TOWNHOME 1634 SO FT TAP
Park Impact Fee - Single Family/Townhome
Sewer Connection Residential Fee
3/4 Water Meter Residential Connection Fee
Public Safety Impact Fee -Admin
Transportation Impact Fee - City
Irrigation 3/4 Meter
Plumbing Permit Fee
Public Safety Impact Fee -Police
Driveway Fee
Electrical Permit Fee
Building Valuation: $250,320.00
Electrical Valuation: $37,548.00
Mechanical Valuation: $17,522.40
Plumbing Valuation: $25,032.00
Total Valuation: $330,422.40
Total Fees: $14,563.97
Amount Paid: $14,563.97
Date Paid: 10/412022 3:49:22PM
38172 Fallstone Way 15 26 21 0230 00000 0420
Contractor: LENNAR HOMES LLC
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$769,56
SIF 1 percent Fee
$33.53
$2,090.00
Transportation Impact Fee
$3,445.20
$732.71
Building Permit Fee
$1,291.60
$26.35
Water Connection Residential Fee
$1,010.00
$34.80
Fire Wall/Smoke Wall Inspection
$15.00
$732.71
Mechanical Permit Fee
$127.61
$165.16
School Impact Fee - Single Family
$3,353.00
$254.00
Admin Fee / (Provider Service)
$180.00
$45.00
Address Fee
$30.00
$227.74
REINSPECTION FEES: (c) With respect to Reinspection fees will 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 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 permit required from other governmental
entities such as water management, state agencies or federal agencies.
Pfif�- w racisif i
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Complete Plans, Specifications add fee 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 SIGNATURE PE IT OFFICEt)
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER I
813-780-0020 City of Zephyrhilis Permit Application Fax-813-780-0021
Building Department
Date Received Phone Contact for Permitting 908 770 -_ 7763
Le nnar Homes, LLC nt�7
Owner's Name Owner Phone Number 813.574.5700
Owner's Address 4301 W Boy Scout Blvd, Ste. 600, Tampa, FL 33607 Owner Phone Number
Fee Simple Titleholder Name Owner Phone Number
Fee Simple Titleholder Address N/A
JOB ADDRESS 38172 Fallstone Way LOT # 0042
SUBDIVISION Townes at Autumn Paim] PARCEL ID# rl 5-26-21-0030-081 00-0010
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED NEW CONSTR 8 ADD/ALT SIGN DEMOLISH
P INSTALL REPAIR
PROPOSED USE 0 SFR COMM OTHER
TYPE OF CONSTRUCTION 110 BLOCK FRAME STEEL
DESCRIPTION OF WORK Multi -family / Screen Enclosure / Fence
BUILDING SIZE LU/ SQ FOOTAGE [j6� HEIGHT
. . . . . . . . . . .
BUILDING $ 250320 VALUATION OF TOTAL CONSTRUCTION
LfiELECTRICAL 37548______] AMP SERVICE [XJ PROGRESS ENERGY W.R.E.C.
PLUMBING
25032
MECHANICAL $ 0 17522A VALUATION OF MECHANICAL INSTALLATION 1 1
=GAS Z ROOFING SPECIALTY OTHER
r--n
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA LJ YES Do
. . . . . . . . . . . . . . . . . . . . . . . . .
BUILDER COMPANY Lermar Homes, LT.0
SIGNATURE REGISTERED Y/ N FEE CURREN
Address
14301 Boy Scout Blvd Suite 600 Tampa, FT. 33607 License CGCI-518166
I I
ELECTRICIAN COMPANY Edmonson Electric, Inc.
SIGNATURE REGISTERED / N FEE CURREN
Address License# EC13005408I
PLUMBER COMPANY Bayonet Plumbing, Heating & AC, Inc
SIGNATURE REGISTERED Y/ N FEE CURREN Y/N
Address License # I CFC042998
MECHANICAL COMPANY Bayonet Plumbing, Heating & AC, Inc
SIGNATURE REGISTERED Y/ N FEE CURREN LILN
Address License #
OTHER COMPANY C iterlingQuality Roofing, Inc
SIGNATURE REGISTERED Y/ N FEE CURREN I Y/N
Address License# CCC057991
RESIDENTIAL Attach (2) Plot Plans, (2) sets of Building Plans; (1) set of Energy Forms, R-O-W Permit for new construction,
Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans w/ Silt Fence installed,
Sanitary Facilities & 1 dumpster, Site Work Permit for subdivisions/large projects
COMMERCIAL Attach (2) complete sets of Building Plans plus a Life Safety Page; (1) set of Energy Forms. R-O-W Permit for new construction.
Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans w/ Silt Fence installed,
Sanitary Facilities & 1 dumpster. Site Work Permit for all new projects. All commercial requirements must meet compliance
SIGN PERMIT Attach (2) sets of Engineered Plans.
****PROPERTY SURVEY required for all NEW construction.
Directions:
Fill out application completely.
Owner & Contractor sign back of application, notarized
If over $2500, a Notice of Commencement is required. (A/C upgrades over $7500)
— Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letter from owner authorizing same
OVER THE COUNTER PERMITTING (copy of contract required)
Reroofs if shingles Sewers Service Upgrades A/C Fences (Plot/Survey/Footage)
Driveways -Not over Counter if on public roadways..needs ROW
NOTICE <]FDEED RESTRICTIONS: The undersigned understands that this permit may besubject to^deed^restrictions"
which may bemore restrictive than County regulations. The undersigned eosumeereyponaibi|hyhzrcomp|ianoewdheny
applicable deed restrictions.
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired o contractor or
contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the
contractor is not licensed as required by |aw, both the owner and contractor may be cited fora misdemeanor violation
under state law. If the owner or intended contractor are uncertain as to what licensing requirements may apply for the
intended work, they are advised to contact the Pasco County Building Inspection Division —Licensing Section ot727-847-
8ODQ. Furthennore, if the owner has hired o contractor orcontractors, he is advised to have the contractor(s) sign
portions of the "contractor Block" of this application for which they will be responsible. If you, as the owner sign as the
oontnanbor, that may beon indication that heisnot properly licensed and ionot entitled 0upermitting privileges in Pasco
County.
TRANSPORTATION |X0P/\CT8JT|L|T!ESIMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that Transportation Impact Fees and Recourse Recovery Fees may apply tothe construction of new bui|dinDa, change of
use in existing bui|dings, or expansion of existing bui|dinge, as specified in Pasco County Ordinance number 89-07 and
90-07. as amended. The undersigned also undorstonde, that such hs*s, as may be due, will be identified etthe time of
permitting. It is further understood that Transportation Impact Fees and Resource Recovery Fees must be paid prior to
receiving a "certificate of occupancy" or final power release. If the project does not involve a certificate of occupancy or
final power release, the fees must be paid prior to permit issuance, Furthermore, if Pasco CountyVVater/Sevver Impact
fees are due, they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW (Chapter 7i3,Florida Statutes, oeanmended)� |fvaluation ofwork is$2.50OOOormore, |
certify that |, the app|ioant, have been provided with a copy of the "Florida Construction Lien Law —Homeowner's
Protection Guide" prepared by the Florida Department of Agriculture and Consumer Affairs. If the applicant is someone
other than the "owner", | certify that | have obtained a copy of the above described document and promise in good faith to
deliver ittothe ''mwner^prior tocommencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT: | certify that all the information in this application is accurate and that all work
will be done in compliance with all applicable |owa regulating conu(mction, zoning and land development, Application is
hereby made to obtain a permit to do work and installation as indicated. | certify that no work or installation has
commenced prior to issuance of permit and that all work will be performed to meet standards of all |mwo regulating
oonotruotion. County and City nodeo, zoning regulations, and land development regulations in the jurisdiction. | also
certify that | understand that the regulations ofother government agencies may apply to the intended vvork, and that it is
myresponsibility toidentify what actions | must take tobeincompliance. Such agencies include but are not limited to:
- Department ofEnvironmental Protection -Cypress Bayheado. Wetland Areas and Environmentally Sensitive
Lands, VVa(er/WaotevveterTreatment,
- Southwest Florida Water Management District -Wells, Cypress Bayheedm, Wetland Areus, Altering
Watercourses.
- Army Corps ofEngineere'Seevva||a.Docks, Navigable Waterways.
- Department of Health & Rehabilitative Services/Environmental Health Unit-VVa||o, Wastewater Treatment,
Septic Tanks.
- USEnvironmental Protection Agency -Asbestos abatement.
Federal Aviation Authority-Runwayo
| understand that the following restrictions apply tothe use offill:
- Use offill ianot allowed inFlood Zone Wrunless expressly permitted.
- If the fill mehario| is to be used in Flood Zone ^A^, it in understood that e drainage plan addressing a
"compensating volume" will be submitted at time of permitting which is prepared by a professional engineer
licensed bythe State ofFlorida.
- If the fill material is to be used in Flood Zone ^A" in connection with a permitted building using aham wall
construction, | certify that fill will be used only hufill the area within the stem wall.
- If fill material is to be used in any area. | certify that use of such fill will not adversely affect adjacent
properties. If use of fill is found to adversely affect adjacent propedi*s, the owner may be cited for violating
the conditions of the building permit issued under the attached permit application, for lots less than one (1)
acre which are elevated byfill, onengineered drainage plan iarequired.
If | am the AGENT FOR THE OWNER, | promise in good faith to inform the owner of the permitting conditions not forth in
this affidavit prior to commencing construction. | understand that a separate permit may be required for electrical wodk,
p|umbing, oigns, weUa, pon|a, air condihoning. Aos, or other installations not specifically included in the application. A
permit issued shall boconstrued tobeo license to proceed with the work and not esauthority toviolate, nanou|, abar, or
set aside any provisions of the technical oodeo, nor shall issuance of permit prevent the Building Official from thereafter
requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid
unless the work authorized by such permit is commenced within six months of permit iaauonna, or if work authorized by
the permit is suspended or abandoned for a period of six (6) months after the time the work is commenced. An extension
may be nequested, in writing, from the Building Official for a period not toexceed ninety (QO) days and will demonstrate
justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the job is considered abandoned.
OWNER cmAGENT-
Subscribed
7/28/2022 by Christopher Smith
3re me or
as identification.
Notary Public
Commission No. Gszeeos,
Stephanie Farmer
CONTRACTOR
Subscribed and sworn to (or affirmed) before me this
7/2W2022 bv Christopher Smith
Who is/are personally known to me or has/have produced
as identification.
Notary Public
Commission No. GG 296057
Stephanie Farmer
Name of
7
Project Name:
Parcel Tax ID:
UA[ W Notice to Building Official of
Use of Private Provider
Effective January 20, 2003
38172 FALLSTONE WAY
Services to be provided: Plans Review X
Inspections
Note: If the notice applies to either private plan review or private inspection services the Building
Official may require, at his or her discretion, the private provider be used for both services pursuant to
Section 553.791(2) Florida Statute.
STEVE SMITH
the fee
owner, affirm I have entered into a contract with the Private Provider indicated below to conduct the services
indicated above.
Iiii Fil Pllliili 11
Private Provider Finn:
Private Provider:
Address: 747 SW 2ND AVE- SUITE 170,301,357,& 358, GAINESVILLE, FL 32601
Telephone: 813-376-3088 Fax: N/A
Email Address (Optional): deb@virtualreviewassist.com
Florida License, Registration or Certificate #: (LIC # BU1967/ PX2300/ BN4615)
I have elected to use one or more private providers to provide building code plans review and/or inspection
services on the building that is the subject of the enclosed permit application, as authorized by s. 553.791, Florida
Statutes. I understand that the local building official may not review the plans submitted or perform the required
building inspections to determine compliance with the applicable codes, except to the extent specified in said law.
Instead, plans review and/or required building inspections will be performed by licensed or certified personnel
identified in the application. The law requires minimum insurance requirements for such personnel, but I
understand that I may require more insurance to protect my interests. By executing this form, I acknowledge that I
have made inquiry regarding the competence of the licensed or certified personnel and the level of their insurance
and am satisfied that my interests are adequately protected. I agree to indemnify, defend, and hold harmless the
local government, the local building official, and their building code enforcement personnel from any and all
claims arising from my use of these licensed or certified personnel to perform building code inspection services
with respect to the building that is the subject of the enclosed pen -nit application.
I understand the Building Official retains authority to review plans, make required inspections, and enforce the
applicable codes within his or her charge pursuant to the standards established by s. 553.791, Florida Statutes. If I
make any changes to the listed private providers or the services to be provided by those private providers, I shall,
within I business day after any change, update this notice to reflect such changes. The building plans review and/or
inspection services provided by the private provider is limited to building code compliance and does not include
review for fire code, land use, environmental or other codes.
The following attachments are provided as required:
1, Qualification statements and/or resumes of the private provider and all duly authorized representatives.
2. Proof of insurance for professional and comprehensive liability in the, amount of $1 million per
occurrence relating to all services performed as a private provider, including tail coverage for a minimum
of 5 years subsequent to the performance of building code inspection services.
Individual
(signature)
Print
Name:
Address:
Telephone
No.:
Please use appropriate notary block.
STATE OF FLORIDA
COUNTY OF ALLSBOROUGH
Individual
Before me, this day of
,20_,personally
appeared
who executed the foregoing instrument,
and acknowledged before me that same
was executed for the purposes therein
expressed.
Corporation
LENNAR HOMES, LLC
Print Corporation Name
By:
(signature)
Print
Name: Christopher Smith
Its:AuthorizedAgent -
Address: 700 NW 107th Ave
Miami, FL 33172
Telephone
No. 813-574-5700
Corporation 22ND
Before me, this day of
MAY -2o22,
personally appeared
of
Lennar Homes, LLC a
corporation, on
behalf of the state corporation, who
executed the foregoing instrument and
acknowledged before me that same was
executed for the purposes therein
expressed.
Personally known X ;or Produced identif cation- Type of identification produced
Partnership
Print Partnership Name
In
(signature)
Print
Name:
Its:
Address:
Telephone
No.:
Partnership
B efore me, this day
of 20_,
personally appeared
partner/agent on behalf of
a partnership, who executed the
foregoing instrument and
acknowledged before me that same
was executed for the purposes therein
expressed.
Signature of Notarjj � OA � a Ln_ PrintName ASHLEE CALLAHAN
Notary Public, Stamp:
Jx ASHLEE CALLAHAN
Commission Expires:
F[oflda
Notary Public- State of
C(I 144456
NOVEMBER 30, 2022
qcotnm ixpi(m Nov 30,2022
N L ry Assn,toftad throqh Natrona, 0
VR//\
VIRTUAL REVIEW ASSIST
Private Provider
Plan Compliance Affidavit
Private Provider Firm: Virtual Review Assist, Inc.
Private Provider: Debra Anne Klahr, BU 1967
Address: 747 Southwest 2,d Avenue
Gainesville, FL 32601
Phone: 813-391-2959
Email: lucyp_virtualreviewassist.com
Project: New SFT'
Address(s): 38156,38162,38168,38172,38176,38180,38184,38188Fallstone Way
I hereby certify that to the best of my knowledge and belief the plans submitted were reviewed for and
are in compliance with the Florida Building Code and all local amendments to the Florida Building
Code by the following affiant, who is duly authorized to perform plans review pursuant to Section
553.791, Florida Statute and holds the appropriate license or certificate:
Name: Debra Anne Klahr
Plan Sheets: 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,LI,SN,SNI,S3,S4,S5,S6,SS,ST,D1,WP,
PAI.0,PAI. l,PAI.2,PAI.3,SHI.0,SHI. l,SHI.2,SHI.3,SHI.4,SHI.5
Florida License/Registration/Certification #(s) and description:
FS468 Certified Standard Plans Examiner
License #: PX2300
Signature of Reviewer:
SWORN AND SUBSCRIBED before me by Debra Anne Klahr
being personallye or having produced as identification
and who being fully sworn and cautioned, state that the
true e best of his/her knowledge or belief.
fore
Z I -_
gg'ni;7e of Notary Print Name
Notary Public: NOTARY STAMP BELOW My
A ASH! H CAL-1 iA
commission expires: e oonda,
GG 2444�
"C' �0' My colylm' E" 22
Eorded t' _n Nits Assr.
uYi
TRACKING #
FOLIO# 38172 Fallstone Way
FIRE MARSHAL #01 -
DATE: 8-8-2022
EY-1LUI'LEV,: Debra Klahr VX230(
IV Building
[:1 Inspection OnLy
V Plumbing
E] Inspection Only
V Mechanical
0 Ins pe tion OnL
V Electrical Amp
Ej Inspection Qnlv_
44 Roof
-
[:1 Gas
I
I
El Medical Gas
E:1 Fire Sprinklers
F-I On Site Piping
0 Fire Line
[:] Irrigation
0 Fire Alarm
El Potable Backflow Assembly
0 Fire Line Backflow Preventer
EJ Irrigation Backflow Assembly
E:1 Demolition
❑ Walk-in Cooler
El Refrigeration
0 Hood
El Ansul
F-1 Fence/Wall
❑ Grease Trap
El Other
0 Other
RTMrIT11 �u I
Ty e Construction:
—T
Risk Category:
Occupancy Load
OVan, Classification:
Fac 'YCs
Factory
Residential
Assembly Business Care/Educational
Hazardous , Institutional E==FO�eyrcantile
'Storage ❑
ty
Util
Building Use: Single Family r_--
Alteration Level I Level2rEl Level 3
Z
%Z New Construction ❑ Interior Finish ❑ Interior Remodel ❑ Exterior Remodel F Addition ❑ Revision
Overall Size:
18 x 63
Number of Stories:
2
Total Sq. Ft.:
2086
Living Area: 1634
Covered Area: 452
# of Bedrooms: 3
# of Baths: 2.5
Cost per square foot:
Estimated Value:
Roof Type: 21 Shinle
[—]Tile 0 Built-up D Metal F-1 Other Squares: 14
Zoning:
Wirdborne Debris:
D Inside Outside
0
Energy Code:
405-2020
Flood Zone: X Base Flood Elevation: Finish Floor Elevation:
Hydrostatic Vents? ro Yes No --Tsq. Ft. Enclosed Space Below BFE:
# of Vents:
Size of Vents:
Total Sq. In. Permanent Openings
9 Central A/C
El Gas A/C
FX-1 Heat Pump El Window A/C
El Gas Heat 0 Electric Heat
I 14TWITMI1,00T MIE
Sanitary Sewer
Storm Sewer Catch Basins
Potable Water
Underground Fire Line
Setbacks
Front Rear Left Right
rv'l As per Approved Site Plan
Comments:
DESCRIPTION; LOTS) 39 46, TOWNES AT AUTUMN PALMS,
6)
SEC, 15,Lb'Yp. 26 S, RNG 21 E
1708 Water Oak Drive
ACCORDING TO THE PLAT THEREOF, RECORDED
IN PLAT BOOK
S.
PASCOOUNTY,
FLORIDA
�J
PAGES) OF THE PUBLIC RECORDS OF PASCO COUNTY,
FLORIDA.
I
( TOWNES AT AUTUMN PALMS)
:
Tarpon Springs, Florida
I 2� D' IPA
r I
Phone: (727j-831-1990
N89'56'08"W)P)
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ALL ELEVATIONS REFERENCED
104.98 )P)
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TO NORTH AMERICAN
SITE PLAN
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VERTICAL DATUM OF 1988
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PROPOSED ELEVATIONS AND TYPE
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FORM TFiE ENGINEERING PLANS OF MASEReo
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LEGEND
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LOWEST FLOOR ELEVATIONS:
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SURFACE TYPE FENCES
LIVING AREA 8500
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NORTH AMERICAN VERTICAL DATUM OF
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ENTRY 173
G'1AIN N((t NCE
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ENTRY 671.
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LEGEND:
COVERED LANAI 8 68 _ so F7-.
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ENTRY
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CONC DRIVE 1971_
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A/C & CON( PAD 80
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SO_ FT. n _ �.,
SIDEWALK _ 334_ SO. FT ol c,
SIDE YARD SWALE NA SO. FT.
l89 5608 1 fill lo/ 0 0"
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INGRESS RESS/UE & D_E
APPARENT FLOOD HAZARD ZONE:'XX COMMUNITY NO. 120235
___
AREA NA
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o LOT UNIT C ENTRY n.3 0
CONSERVATION SO Fl-
`-'
44 16Z4
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MAP NUMBER 12101C-0452 f EFFECTIVE DATE: 09/26 2014
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LOT OCCUPIED 59 Kl
AREA TO IRRIGATE 41 /
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SURVEYOR'S NOTES:
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397
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Current title ton the subject property , ri
NOTES:
n o 0 o o
< P P P �,
E V RY„
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fu Initial Lad L
urnished to Initial Pofnt and Surveying t LC at the nm oft[hrs site plan
Pointtime
LOT GRADING TYPE = N/A
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2.) This sketch was prepared without the benefit of a title search No
Z45
Y
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g ownership, easements or rights olfway
instruments of record refl - £n crzhl
PROPOSED PAD ELEVATION = N/A
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SIDE SETBACK - 10
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This SITE Plan Prepared
for and Certified To:
NOT VALID W�IT(yy�jf E-EiR( NATURE AND SEAL
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UFA FLORI^�f ***ttt��V OR AND MAPPER
Permit No. i
Date Permitted
Builder Name/Owner Name j\, Control #
County Parcel No. 's 2�-z 2-1 00,50 0 6 0 QQ 00/0ubDiv:
Address/Location ,3 ��0 {
Classification/Type of Use + 0
TRANSPORTATION IMPACT FEE Rate: Sq. Ft Unit: E 1(0,3q
Exempt 0 Yes No tt How Determined
Impact Fee Amount Zone No. TAZ:
SCHOOL IMPACT FEE
Account (056) Single -Family Detached House Amount $
(057) Mobile Home
(058) Other Residential
(123) Collection Fee
Exempt =Yes = No How Determined_
PARKS AND RECREATION FEE
Land Account Land Credit Land Total
Recreation Account Recreation Credit Recreation Total
Zone Total Amount $_4
Land Account Land Credit Land Total
Facility Account Facility Credit Facility Total
Exempt Yes No How Determined Total Amount
RESOURCE FEE ERU
Total Amount
Prepared By v ----R _ Checked By
NO CERTI CATE OF OCCUPANY WILL RE ISSUED OR FINAL INSPECTION
PERFORMED UNTIL THE TOTAL AMOUNTS LISTED HAVE
BEEN PAID AND RECEIPTED FOR BY A CENTRAL PERMITTING OFFICE OF PASCO COUNTY
ACKNOWLEDGEMENT BELOW DOES NOT IMPLY ACCEPTANCE OF CONCURRENCE, BUT SIMPLY REECEIPT OF A COPY OF THIS
FORM, PLACING THE BUILDING OWNER ON NOTICE OF THIS ASSESSMENT AND THE CONDITIONS OF PAYMENT FOR SAME.
DATE RECEIVED BY
RECEIPT NO DATE __ __ — BY