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HomeMy WebLinkAbout95-5214 BUILDING PERMIT~ CITY OF ZEPHYRHILLS Permit. (813) 788-6611 ~~521t IJ Date !S-rl9-9~- bS~n dlo. VU ELECTRICAL "2j:J,, c)V PLUMBING MECHANICAL Sewer Conn Water Conn: BUILDING Pmperty Owne" . J\";if; -4~ JobAdd,e'",~~ hJ P"ceII.O. . <..j""~~ - 0 If.. ." 6' CJ EJ - O?J' 0 Radon Gas: ~ Water Meter: T,I.F.'s: Zoning: Energy Code: Description of Work JA'L!~~41 c/ ~ ;1/ ~;~L?t'1 r~ r;?e~~3Y~ df~7~ NO OCCUPANCY BEFORE C.O. FINAL -J?J-l(,"> DATE Complete Plans, Specifications and Fee Must Accompany Application. C.O. All work shall be performed in accordance with City Codes and Ordinances. Inspector Permit Fee Signature Company Address Telephone# ./ v J:J-: <Jt-K- t::TtJ ,,"\.~v, Valuation or Contract Price 9 336. IhJ ./ City license Registration # ~ I 7 State Certified license# ~~.~ ~&Li!&67 '}j~~~ ;LJ /' ELECTRICAL ~"E. U,. ..., ~-/~ Tp. Servo ~, LL Rough In Meter Can Const. Pole Pool Pre-Meter Final 11-1 ~ -tj,. 6cu- ~)t. ~...13-q5~ PLUMBING f -5,q~ 61l'- - MECHANICAL SLB Tub Set Water Sewer b Final 11- ) 1:; ~ 5', U- Breakers Ducts Insl. Compressor Final ~n:~I: cLb~g~~; WL l \.-1 r.:t> \ v....... Driveway REINSPECTION FEES: When extra inspection trips are necessary due to anyone of the following reasons, a charge of Fifteen and 00/100 Dollars ($15.00) shall be made for each trip for each trade: a. Wrong Address b. Condemned work resulting from faulty construction. c. Repairs or corrections not made when inspection called. d. Work not ready for inspection when called. e. Permit not posted on job site. f. Plans not at job site. g. Work not accessible. The payment of inspection fees shall be made before any further permits will be issued to the person owning same. <3 .. . ,..~ ,~o ~ /:;....... - Z ~ U) ,~ " :j ,~ ,.. ~ d =~ J B S ~ ! _I ~ ~ - ~ I ~ I I I ,) I I ~ '=-' -..,J 9 J I ~ "'J I (' -- '-:.-''1. \:" , ..x I!~ ~a .1! ;110 It p & Ii! I" --J r><\ \0 ,) C; -.j -.J ~,' ........" - Q"~ r"'- I L[? , , w ! i ~V--~ I I I I i ;;;; o '+ "P -( j ( w -j~ I -b I~ y- 'v-> I- I I i I \ I I ! I i i l I , I I ... .-- '__d____~_ ----s\ \J,: '-- ')>J W " ....::J f'\, V) ""\ ~Q " _ ~ c.. ~, a / \:) ;u (\ ~; ~ r, ---, 'l::. ~ --. ~ A "1 ~~..M~~~~~~~.~~~~~~Pp~p~~~~~~~~~ i;lllil~ii~~;li~II~I~~lli~I~~ :~Srl.; imA l~i~.~I;,iil!:t~1 00( · '..f Elt-P)>i '-")('" () , { "''', ,j I; ~ () 1 't - oJ I" 'tl 't' !' I v' ,_ -( \ '- ; ,:I Ii \ \ . "I v ~' . · 'i J I =1 : I i ~~ '0 I to .; l ~ S' · I( ~ ~ /- e r. l I,. ~ ~~ a "rJ/ F r DATE: August 11. 1995 NAME: GIRARD. PIERRE ADDRESS: 6141 RIDGEWAY DR LOT 73 ZEPHYR RIDGE ACCOUNT NUMBER: WREC RELEASE #: 1422 080 437 480 95-080 APPROVED: YES DISAPPROVED: REASON: INSPECTED BY: RON HAMILTON DATE: Auqust 11. 1995 APPROVED BY: RON HAMILTON DATE: Auqust 11. 1995 OTHER: POOL COMPANY: HOMETOWN POOLS P.O. Box 1278, San Antonio, FL 33576-1278 Phone (904) 588-5115 Fax (904) 588-2505 ~," .....,. '...~ '.... -. ~"""'''''''-"'''- ,~.,-='y...!'t" APPLICAnON FOR PBRKIT CITY OF ZEPIIYRBILLS BUILDING DEPARTHENT OWNER'S NAHK ,.: '-t.' J('l?....e Q ~ \ \of' Art. cl 0'1 '" \ c\S t" Lt d<J. '/ PHONE OWIIER'S ADDllBSS (n j '4 I JOB ADDRESS S-' f) i11 .",,- ........ LEGAL DESCIlIP'lION: LOT(S) BtoCIL.-SUBDIVISION 2~).n RI d5~ PARCEL LD.'':;' 2" :l. ( 0 I "bo CG6GO c~ 73C (OBTAIN FROM. PROPERTY TAX NOTICE) WORK PROPOSED:~ew CoDstruction ---Addition --...Alteration -.Jlepair _Install _Si8l1 -.JIove ~lish PROPOSED USE: ~iDg1e Faaily _ec-ercial --.Jf./F _' of Units --.Jf./H _Indust. 4SWia. Pool _OtJ;1er Restaurant &: Health Departaent Approval DESCRIPTIOII OF WORK: Q QA( t...(( '-'l 'f<, gc L BUILDING SIZE: x Square Feet, Height RESIDERTIAL: COMMERCIAL : ATTACH (2) PI.OT PLANS &: (2) SETS OF BUILDING PLANS &: (1) SET ENERGY FORKS. ArlACH (3) SETS OF BUILDING PLANS &: (1) SET ENERGY FORKS. PROPERTY SURVEY REQUIRED FOR ALL NEW CONSTRUCTION. PBRKITS REQUESTED ~UILDING $ ,3 3t:, I> 00 Valuation of Total Construction RI.RcrBICAL AIIP Service Florida Power Corp. W.R.E.C. --"BawnCAL $ Valuation of Kecbanica1 Installation .-PLUKBDlG GAS ROOFING TYPE QF COIISTRUCTION: ~loclt _Fraae _Steel SPECIALTY Other FIIIISIIED .FLOOR ELEVAnOIlS: FT. IS PROJECT IN FLOOD ZONE AIlEAT YES NO .......................................... BIITJ.DRR COBTRACTOR SECTION cotIPABY--1J.o rv,~~ t(j t-\J State Cert. or Regist. . City License Registration . .......................................... RJs I;. '-- c.pc cJ;).S5."-/~ Sisnature SionJlture COMPANY '[k,A.JN 1\ /;z 2Jv #- J ,'€J kt ~-L Cu". t " ,- . " State Cert. or Regist.' ~, 'I ~....O'r"i/....",,:, '/jifJ,rt-t..~b. (; City License Registration . . ....................................... l'nU'D.&uv I' ,I" \ j, (1-)Q..,J~5 UUDrftlU. f'.:t<.:, ., ~- rH..... v ! ~ "- State Cert. or Regist.' <::,Pc c J.. ",-~V-~ ~ll {Q.~7 City License Registration' .......................................... PLlDlBER ~~; Signature' ", / IlECllANICAL COHPANY State Cert. or Regist. . Signature City License Registration . .......................................... OTRRR COHPANY State Cert. or Regist. . Signature City License Registration . .......................................... APPLICAnOIl APPROVED BY PBRKIT OFFICER. CONDITIONS OF PERMIT AFFIDAVIT A. NOTICE OF DEED RESTRICTIONS 'l'be undersigned understands tbat this perlit JaY be subject to -deed restrictions- wbich lilY be lOre restrictive than City regulations. !be undersigned asBUJeS responsibility for CCIIpliance with any applicable deed restrictions. B. UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES If the OImer bas hired a contractor or contractors ~ to undertake work, they .y be required to be licensed in accordance with state and local regu1atiOll8. If the contractor is not licensed as required by law, both the 0IIIleI and contractor lilY be cited for a lisdelll!anor violation under state law. If the owner or intended contractor are uncertain as to wbat licensing requirelll!llts lilY apply for the intended work, they are advised to CODt..act the City of Zepbyrbi11s Building Departlent, (813) 788-6611. FurtheIlOre, if the 0IIIleI bas bired a contractor or contractors, be is advised to have the contractor(s) sign portions of the -Contractor Sections- of this application for wbieb they lIi11 he responsible. If you, as the OIIler sign as the contractor, you are indicating tbat you, rather than the contractor, are respoosible for the work. If the contractor wi8bes you to sign as contractor tbat lilY be an indication that be is not properly licensed and is not entitled to peIlitting privileges in the City of Zepbyrbills. C. TRANSPORTATION IMPACT FEES AND UTILITY CONNECTION FEES D. CONSTRUCTION LIEN' LAW (CHAPTER 713, FLORIDA STATUTES, AS AMENDED) I certify tbat I, the applicant, have been provided with a copy of -Florida's construction Lien Law - lkIIeoImer's Protection Guidell prepared by the Florida Departlent of Agriculture anciConsUIBI Affairs. If the applicant is ~ other.than the -OIIDerll, I certify that I bave obtained a copy of the above described docuIent and prolise in good faith to deliver it to the 1I000er- prior to COllBllCl!lBllt. E. CONTRACTOR'S/OWHER'S AFFIDAVIT I certify that all the infOIliltion in this application is accurate and tbat all work lIill'be done in CCIIpliance with all applicable laws regulating construction, loning, and land developlBDt. Application is hereby lade to obtain a peIlit to do work and, installation as indicated. I certify tbat no work or installation bas CDIeIlced prior to iuuance of a perlit and that all work will be perfOIllld to Jeet standards of all 1_ regulating construction, City codes, loning regulations, and land develO)llBJlt regulations in the jurisdiction. I also certify tbat I understand tbat the regulations of other gOYerDlBDtal agencies lilY apply to the intenc1ed IIOrt, and that it is If responsibility to identify wbat actions I lUSt take to ,be in COIpliance. Such agencies include but are not lilited to: I Departlent of BnvirOlllBl1tal Regulation - Cypress Baybeads, Wetland Areas and BnviIOllll!Dta11y Sensitive Lands, Water /Wastewater 'l'reatlent I Southwest Florida Water ManagBlBDt District - Wells, Cypress Baybeads, Wetland Areas, Altering Watercourses I AIIY Corps of Engineers - Seawalls, Docks, lavigable Waterways I DepartJent of Health i Rehabilitative Services, Bnvirouental Health Unit - Wells, Wastewater 'l'reatlent, Septic!anks I US BnviIODleDtal Protection Agency - Asbestos abatelll!llt I also certify that, if fi11lilterial is to be used in Flood zone IIAII or HA,etc.lI, it is understood tbat a drainage plan addressing a llCOJP1lDSating vol_II will be sublitted wbich is prepared by a professional engineer registered in the State of Florida prior to peIlit issuance. A ~it issued shall be construed to be a license to proceed with the IIOrk and not as autborityto ,iolate, caDCel alter, or set aside any provisions of the technical codes, nor shall issuance of a peIlit prevent the Building Official frol thereafter requiring a correction of errors in plans, construction, or violations of any code. Ivery pemit issued aball bec:oE invalid unless the vork authoriled by such perlit is ~ced within sillODtbs of issuance, or if vork autboriled by tile perlit is suspended or abandoned for a period of sil IODtbs after the tile the vort is ~ced. ODe 90 day stension of tile, laY be allOlled for the perlit with fee charge of $15.00. 'l'be stension shall be requested in writing to the Building Official. An approved inspection lUSt be logged during each sil IODth period, or the project will be considered abandoned. WARRING '1'0 <*IIR: YOUR FAILURI '1'0 RECORD A 10'l'ICK OF <XIIIDCBIIII! MAY RESUL'I' II YOUR PAYIIG fiICK FOR IMPROVIIIII'lS 'l'O YOUR PROPIR'I'Y. IF YOU IJIDID 'l'O OB'lAD FIWCIIG, COKSUL'l' 1lI'l'B YOUR LODER OR AI AftORIBY BIFORI RICORDIIG YOUR IO'l'ICE OF C(JUII:r. JOBS OIDBR $2,500 II VALUE DO 10'1' DID 'l'O RECORD AID POS'l' A III , OF ClIUIIICBIIII!-. ~ ~ / I ( ~ _1- .-/ . ~P/J'LL ~~ ;4' S GIA!UIlI: (MIIR S'l'A'l'! OF FLORIDA flt COumOF tl~ The foregoing instrument was acknowledged before me thiS!J'7 JIn , 19-2.2: by STA'l'B OF FLORI~ coum OF ~ The foregoing instrument was acknowledged before me this 07 l/.p. ' 19 -2:S::... by r7 who is personally known to me or who has produced ,,\\ . . as identificaJt~..~~d,..~did/did not take an oath}.,./ cI. ~ (})~-A~ . \- (Signature) '~<I'\'. .:' + t _ ~I't-.v a~ ....~ - :T~~ >'l ~(:---' v (Name ed, ~4itAil.;Qt:,~ amped) III r""f \. ,\' ROTARY PUBLIC //1/1111111,,\1\\' who is personally known to lie or who has produced as identifica~~. HII;~,who did/did not ,-,-' . -'1;l y p "///. take an oat:\l!"~::T...~~~ r;n/(~". ....~ (Signature~ . f . (' S "P r 11 ~ tAn *1. !~ Z-tV t4 PE L- (Name Type~v~l;'inted ..~ -Stamped) ROTARY PUB~ ................~ \.~,,:'" ,Or f \. I7l ", ///1/11111\ II \11\\\' Notary Public, State at Fiorida DIANNA L. Tf/ZNADEL My Comm. Exp. Nov. 11, 1995 Comm. No. CC 159184 Notary Publk SL: , DIAf"..JNA l l~t7c~~~-''-'llUd My Comm. Exp. N'o~: 11,":'t .J95 Camm. No. CC 159184 -----------------.~._._- ---.-.---------.---------------------- I C c - j ""J_ Hometown Pools, Inc. 37008 Price Dr. ZephyrhiJls, FL 33541 813-782-70n . . "0..... .-. .-ooe. ... .,.".. ;TANOAAO RESIOENnAL IMMING POOL CONT;::;ACT ;;:1. TAMPA cAY CHA?'icR This cont~ct made as of t"e date 01 wnn.n accectance by Ihe m.mber tlullder list.d aOOve nereinatter lermed -Contractor" and I". party named below. herelnatter termed -Purcnaser.'" PURCHASE~ PIF.'R'RF. ~TR21n 6141 RIDGEWAY Ph. HOM!; MAILING AOORESS Ph. BUS ZEPHYRIDGE ZIP Contractor.vr- 10 constNd . SWlmmtno Poolancl &DOUI1_nces Inetl!10 ., ....r..n.fter 17OV.ded by Ine 01_. soeclfieallons anCllerms 01 tne contract at: INSTALLATION AODRESS SAMF. LEGAL DeSc. ~ 2~ 21 91~Q 00008 0730 POOL SHAPt; PERIMETE~ custom 72 MAX WIDTH 1 2 IIf MAX LENGTH . 24 IIf DI::~' 3 tt. to 4 It. to J:j IIf WATER AREA 288 It. NS?I TYP= :a s/f I. .:xcsas Inl OlJner n. UnCl_aler IiQ",,,,n 1-]?v-100w ~ Filter System DE 65 12. Main drain 1 to Pumo & mOlor 1 HI-' 1:l. Oec:l<AqYRI r c Sa. It. are~ ? '. Mefnoel 01 enlonna lio'" , cl-l00 1~. Oec:x ~jnaQe code 1 ,. R'T'n I. Surl.ce skimmer !5. l..aClder IGnltlrad" 9liclcwli5ft disoosel yes 16. SleoslHandnlll steps Pic..ono & inlet" PVc 17. Oi","9 Sd. & Slant! no ;:--e:.:"~ j.,..;. 2 10. ::..0. nn 21. Timer YAQ 22. T est kif 4-1 ,.... rp;:lm2:!. Vactl\IIn ~e.t! 1 Vact. hose 1 24. Btusn 1 !..eat net 25. Adiuslatlle I'ole 2~. Sta~chem.cal" 4 weeks 27. HeaterXXXXX~XXXXX~~X ~~. .:-..:~:::.::: =t'=3"'~:"' RD--- Color liH,rTi;. MAReITE 19. ~ntilevetJCOOlnc;ltile 20. Elean~ hOOlWl:l r.Ol\T'T' TILE. GFl~ 29. I..ove seat JO. SWlnoout Bench YF.S Tile 6vF. I ntenOl" ft".5ft YES IdltlonaJ Provision" TEMMS Iless SO<<:ra11y agreed and set fortn herein. PurChaser "ere under ao~ 10 malte 1709ress cayments based on lhe lotal I'nce sel 'ortn in 'nis conlract. 10 Ihe .nfractor. as fOllOWS: CO~Acr PRICE $ (:I:I::IH: nn s 9336.00 10.. Cown Qeymenf 5O'llo When rouon snell is in I'leee 35.... When Olumbing IS como"'~ 5.... Wh'Mt pool is comoa.ted. ready 101" inlerior "nisn 4668.00 4668.00 ConSI""ctlon orooreas may De arreSled between odlinq anCl teee.ol CJI o.~.'Tlent /01" eaen onase of COnst""ctlon. NOTICE TO PURCHASER 00 NOT SIGN Tl-4IS CONTRACT BeFORE you REAO IT OR IF PER"NENT INFORMA"ON IS MISSING FROM BUNK SPACES. s IS a nome solicltalion sal.. II yOU dO not want tne QOoas orsef'Oices contracted/Of'. you may cancel tn,s aQreemenl tly ma.ling a nOllC.IO Ine seller. ThiS nOl1ce must ICllte lhat YOU do nOI want rne gooels and servIces and must tie OOSlma",ed tly mldn.gnt Ihe Inltt! day all.,. YOu SlqneCIln. agreemenL '. t:lJ"".r:~ zlt.,1 b. t1..,..,~ ." of"tp,. ro 'Iff! C,,"'r.~tt:l' 4"~ $"." b. ftull."d .o.d U"'''~8 .cr:~I!I'.d b.,. dUly .U'It""IPfI odiC.,,,, ,It. <:",.".r:1D' """,.,,.,,, I,,,,,.,. 0.'" 01 ,It~ "..,. ~ ",~.'t't,,'.d .eo... tit. P\"t:".~.,., S'9".'u,.s. n,. J.'.sm." ".6 no ."''''0'''''' I" Oil'" ,ltf! ClI"'''.:r", All 69'..,"'Utr$ .I"~ U"".~fr.nG"'VS .,. eOllr.'"ffd''' ,,.,. CD"".t:r ."d I ~'r:!'!~$,r -."."'1 ,,,., "'~~~ ~'.,.o "9'.P'""''''''~ 0' UltflP",.,.",r:r;s o,/'t~, ~"~".~ 1.' to"""'" tn.s I:DI::I'".'" Ace~D'."t:~~' ,ft. ,~,l'fI'ts 0' !""""S CD1'!".~r 0,," Co"".t:tO',s '0 e.",""'un'c~,~" ," tn. Puf'T:".,rr 0", ".ns,",nln9 . cat:lt' o/'ft" .:an',...r:: to ~..~'" sItO"""'''9 .C&~II'.nc' C,," ,It. J.II.,. Ot' ~fu, ~."cu"o" 01. dvi.,.utnrHfZ." o",e" 01 ,,,. "'''1:1", ", Dt' eo,"m."C/"'1 C"ft_rrucIIG". ~r= Jl.JLY 18MrrrEO :CE?TEO S 1995 PURCHASER PUACHASRN <:- Date OWNER ~U'''-''- (/Mf-ru,P II OUfcnaSe., afe "usoand and ....e. bcnh musr SlQn. If owner IS dltte,en. from Duren.S.,. owner must S'Qn. ~}04"SERIS1. a' IGNING -'BOVE. .:.Cl<NOWl::DGcS .loNO -'GRE:S iO A.I..L. THE TE~MS ANO CONOITIONS ON ~I..:" PAGES OF THIS ~GRE=MENT EVEN ~I.:GH SP"CE '..IMITATlONS REOUII'lE TMAT SOME .u::re ~QINT;D ;N SMAI..:";~ TYP'!. -- = ~==~=~:::::::=::". LIMITED WARRANTY TN CO"""l..~OA _........ '''' __ ,= 01' _....... __... __ _ _ow... ._.. ",...- ....--.. lor. -- ~ - ,- .n.. CZlII"___I."'__.'"U- ....,~_.......______- _.----~_.._PVlIICHASE.~ .'" :0..""'.'" .... __ ,f' ''''' ..." .... ._. ~ ~..-... ._ _ ~ Of .... _...:= ....JAC,...S(~ ,.-..- - ,,-''I '0 C:OO:-"l...:"OA ac:.cor_~': ,.." _-'IC". .or. ~S_ -,~. -~ '""'="-- ~ .........- --- --.- ---- ..... CD-~ ~"'" .........C1u..... _..,...... ....: COIofTIilAC7:iIl....,_' -...nts or 0"''''- .~ __ - or....-. ___.n-. _..,...... ..... .....<,""' .. -:)t~~-_. ,....c.. ....... __ ~ ~.-'- '":If ...... .-.-c ~_ _a '" _c ...._ct_. - 0.0- or ,- cau....c:"'" eonoul ",..'.":1:9'..- O. .....q~,.... e.. ,..,..-..: 01 .......c..G a: DVAC"ASi::r~ ...... ~. ~.... Slf\C!-:. ......... -=-....... . ......10. .... .........~ IMI " aIY- DI""~ ......:t:r"'.y OU"""lIO mal t..-. T'h." .. -.:"If'y DeCDl'l'ft ~ ~" OI"lQIIfW. DUIC"...... .... tII ....~ a..:ro.c oraoe""'r AN" ,\It: .IEO WAAA...,!', "RIS'''G B'" oPE:QAno.. 0"' !TAn L.A'" IS t.''':TED 1: ~HE OUAAneoo 0"' THe aloe YtJtA w..AAAHTIES "EJ'EIN CX''': .....(0 # , .;1 ( '" ..oa''I'. ....,,,,,_' ".....n",.~ ,n. _ __.C _ "". COfttrC1 ..... 00 ..-eCI to Ifte ~_. .- II - 00 ...oo."I""'G · -' ~ - - __s OEFIN!TIONS no. _ "n,,::;lu'. .na" !WCOft.oo.'eG 10 .."..FO.l',' SA T1S1'ACTOAIt.'" or De 'STRU~AALt. Y SOUND' ... _.... -- 01___-....... .-..-- .._a ....00'...... ", · '5- 'e 3 'r - ".". . 10001. S"EL.1. .. D?:JL ST__uC1\lRe . 1110 cane''''. _ -" ......_ - .- ......ora<'O DIltS 'm_'- - .- Daft "" - .... POOl <!Q........nl _IC'" =-"or"''I 1_ lu"I:l"''' 'or _ocn .. _ "'.10- s..... lW ~...,...., to ',"EQ~"Q'" SATlSFACTOf'l't. T. 'oecll AND P&T10wc;lOC' _,tIO "_1. ..._....c:DftC-.. II'. .no_~--",~-_._____I_'_---"'._--- ..e "".'0....". ....OU......_....AUS...,..'''. _ITE ,N11:Q'OQ "NISH s_" ~. _..urwol-.c:em.'" .""or-nd___n ____,...---.na _IID11~- _ "...... AQI;'tIQ.'" .-.,.l)It ',u" """.au.~ _In ...__,. .m_' OI...._ft. -'cr..._....---..'-... - .,..._toaurt--...."----n \000" 1n. ."'0.,,'" ot CO"" '" 'I'W aoor~'. ~ed LIMITAT10NS No _.....'" ....._s ,. ."., ..n 10 ,... -', ___ or _"on_ _ ,.....,. or ...- .. cauaeCI "., ."., f1I - ~ _.4IIIuO. or --= 0\1>..... laCW d ...-... car.. _ 01 ..........., __....nca. I_ _ttOll: --: - f1I GaII:"'- - - _. F'"zlf'lO "" _... lit" unc.n:U"'eClln OIumO"9 _.. Ii".... __ -. or - __nL Suaslt.....O" ,.",..:oo....nl or _~. ~ ....._ ~ _n.." ___ ..- ._1I8IY ...__"., - GorftNCtor - ItII\JItt - ,,,. -- ,. - f1I ... ... 1'1.08" or __ 0I1fte ooot or oau_' DT u..-norozeel IIOft_ -.en ....Ita .. -.ooa lO or f8rIufW f1I ... -~ W.... ,...... ..._, ......._ or __ _OCn moq.. _08 11'I. - or _Of'. Ct.CX'''O. c........n;. _""9. _......... ItrosGft. DlfttnQ. ~~ _ ...nono; GI _ __ - c:a.-d "., .- 01 -- _lain lftIt ~ f1I ... _. SUD......n.... << _rt.... ort:lS..n ~ "., ._- wa." _ -=- "" not....... oua.iCM .....~ - .. -- - aoar or - -. _...."0 ~ ..... or aoar .. . ,...." ~ _ 1;1....." 01 II.- .- or - oons- ,- "._It 1IW .~. 0..-"10 "" _ -' .... ._or "". _,.....- _1tClUf ~ ..__ -.... ~no:~. ,.".., _roe. 10 _nea. oou'_' lrom "an_an ......"". \o9fttNno. CONDIT10NS __I",,~_o..s""I"'C--""""-~--- The -' .no_._"'...... tIO""" in. ftOl'ft!.'- ,___m.n... - _..ee1.n EXCLUSIONS ... .... _ ~ oau-",_..au"e "O""ai r_ : '....nll""" n_.o,,--"'OO'" ~._ QIM---' -- .rc.._""'lO ".-----... -,..,.,.,. 9._c:nodtlrtl;." ,,,.OM:l<S- ..."..._mortrOrtl diu....."...."O. .....n__ or......._--- _~or....-'"O .".-- ..,.. --,.......- __"'., ,.".,. ~._' . _..._"., .... N........ SIIO.nd POOl .....M.. Nr<r ........ ",_,-, .'__"'0. moftllrlQ or -'"0 _oa::,,"o 1,..__11_131- 1lOOi_"..I...., __I. -~"---.......-,,.--~..-- _,.... Of _ __co ", 1IW C",.....:,.,... . ~. __. _......... ...."'"'0. ~......_. __ __ ,. _"10 ~ _ -=- - -." -- AFT'ER "..e ~ IS I'11.l..ED WITH .ATe' .., ~ _,_ 1:10O"". _. nor tIO -"""' .. ...__ __0 or -- eft - CIUt - - c-r-. __.......,,_.ft...S.......,__..._D.......~orUt..-'ftSlf\Ca....'lrrr- Pu__. .._~__....".~or. --.........- '- _ .. ....,_ ."" __ or __ 10 ._ c-.,_' OftrtCl_ _ ~ __ - .. - '- ~ ~ , ~ _.........-CL Ct.AIM PROCEDURE sy' DATE' 'J. f:i~.4 SIGNATURE OF CONTRACTOR OR CONTRACTOR'S AGENT L/(JC Ool~J-Y.- (;< . ~: _ ~1-'1'oJ PURCHASE~ PURCHASER / I ~~ I I .!-- \~) / ~7 , ~ I .....' i '-..., .. ", /,;,; ; ." II 5 .J' ....... "- ~~~ -- -- I Ij;- I ,r (--- , ( - - ) / I I ~ ' '-tI r< ,- d S-e l._J..jlj- D .') I}.. - " -::::.... I //?, I - ...... / " / ') , &C \) ~ r? I'G~t.. yq.7 J.c 'f ') 3 ~~c,P ~/( /,; r0 <-- I~~ . ... -~ i r ~II '\)t... 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