HomeMy WebLinkAbout04-2988
CITY OF ZEPHYRHlllS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
2988
Permit Number:
Permit Type:
Class of Work:
Proposed Use:
Square Feet:
Est. Value:
Improv. Cost: 7,930.00
Date Issued: 4/22/2004 Name: NANCY KURLlN
Total Fees: 70.00 Address: 5735 14TH ST
Amount Paid: 70.00 ZEPHYRHILLS, FL. 33542
~Qate Paid-=-_4/22/2004_.~_~_------1.____Phone: ...___.. _________
.... Work Desc: RE-ROOF
2988
RE-ROOF
ROOF REPLACEMENT
SINGLE FAMILY RESIDENTIAL
Address: 5735 14TH ST
ZEPHYRHILLS, FL.
Township: Range: Book:
lot(s): Block: Section:
Subdivision: CITY OF ZEPHYRHILLS
Parcel Number:
-- -- ~. 1 ._ H____ ... _ ..
REINSPECTION FEES: When extra inspection trips are necessary due to anyone of the following reasons, a
charge of Thirty-Five Dollars ($35.00) 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
"Warning to owner:-Yourfailure torecord a notice of commencement may resultlnyourpaYlng twice for
improvements to your property. If you intend to obtain financing, consult with your lender or an attorney
before recording your notice of commencement. II
- --------------CompletePlans;- Specifications ana-Fee Must Accorripariy-Appncation~- -- ---~---- -
All "",<:>rks~11 be.performed in accorc!ancE! with Ci~_g>desan~.9-,"-djnan~~
NO OCCUPANCY BEFORE C.O.
--- ...----- -...--- -----..'---...--,..-- -----._-----.-.__.._--- --------._--
~
_ /" c.e~ ~ ~--~--.
~....._~..__..__.._--~_._._.._-~.~._. --. .__..._~.-.
CONTRACTOR SIGNATURE PERMIT OFFI
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
APPLICATION FOR PERMIT
CITY OF ZEPHYRHILLS
BUILDING DEPARTMENT
MCI 3299
DATE RECEIVED ~ t2J.-o 1-
PLANS REVIEW FEE
OWNER'S NAME--.NOnCY K..u.r.J ,~
JOB ADDRESS 5735 ~ th Street
PHONE g 13 783- aLl ao
ZephyrbLJ1.s FL 335~2
LEGAL DESCRIPTION: LOT(S)
BLOCK
SUBDIVISION
PARCEL ID It JJ~l~.~J-OOIIJ- 08,~()O -()%
(OBTAIN FROM PROPERTY TAX NOTICE)
WORK PROPSED: (JNEW CONSTRUCTION
o ADDITION
o AL'l'ERA'l'I ON
(J REPAIR
(J INSTALL
PROPOSED
Os I GN
USE:~GL FAMILY
o COMHERCIAL
DWELLING
(J MOVE 0 DEMOLISH (1.. ROOFING")
(JMUL'rI-FAMILY (J1t OF UNITS (J MOBILE
HOME
(J INDUSTRIAL
o SWIMMING POOL
o OTHER
D RESTAURANT & HEALTH DEPARTMENT APPROVAL
DESCRIPTION OF WORK
BUILDING SIZE
SQUARE FOOTAGE
22. SQS Shin~ Ie.
z .<:;~S Flat' HEIGHT
RESIDENTIAL: ATTACH (2) PLOT PLANS & (2) SETS OF BUILDING PLANS & (1) SET ENERGY FORMS.
COMMERCIAL: ATTACH (3) SETS OF BUILDING PLANS & (1) SET ENERGY FORMS.
PROPERTY SURVEY REQUIRED FOR ALL NEW CONSTRUCTION.
PERMITS REQUESTED
(J BUILDING
$ l,c~ 30 . 00
VALUATION OF TOTAL CONSTRUCTION
(J ELECTRICAL
AMP SERVICE
o FLORIDA POWER
o W.R.E.C.
o PLUMBING
(J MECHANICAL $
o GAS ~ROOFING (J SPECIALTY
TYPE OF CONSTRUCTION: (J BLOCK
VALUATION OF MECHANCIAL INSTALLATION
(J OTHER
(J FRAME
(] STEEL
(] OTHER
FINISHED FLOOR ELEVATIONS
IS PROJECT IN FLOOD ZONE ARI~D YES 0 NO
BUILDER
COMPANY
STATE CERT OR REGIST #
CITY PROCESSING #
SIGNATURE
******************************************************************
ELECTRICIAN
COMPANY
STATE CERT OR REGIST It
CITY PROCESSING It
SIGNATURE
******************************************************************
PLUMBER
COMPANY
STATE CERT OR REGIST #
CITY PROCESSING #
SIGNATURE
**********~*******************************************************
MECHANICAL
COMPANY
STATE CERT OR REGIST #
CITY PROCESSING #
SIGNATURE
*****************************************************************
SIGNATURE
KJf){//l
COMPANY MILBAR <XJNSTRUcrION, INC.
STATE CERT OR REGIST # acc 051562
CITY PROCESSING # 218
OTHER
*****************************************************************
CONDITIONS 01" PERMIT AE'I"IDAVIT
A. NOTICE OF DEED RESTRICTIONS
The undersigned understands that this permit may be subject to "deed restrictions" which
may be more restrictive than City regulations. The undersigned assumes responsibility for
compliance with any applicable deed restrictions.
B. UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES
If the ownec has hired a 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 l'aw, both the owner and contractor may be cited for a 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
City of Zephyrhills Building Department, 813-788-661l.
Furthermore, if the owner has hired a contractor or contractors, he is advised to have the
contractor(s) sign portions of the "Contractor SectionsH of this application for which they
will be responsible. If you, as the owner signs as the contractor, you are indicating that
you, rather than the contractor, are responsible for the work. If the contractor wishes
you to sign as contractor that may be an indication that he is not properly licensed and is
not entitled to permitting privileges in the City of Zephyrhills.
C. TRANSPORTATION IMPACT FEES AND UTILITY CONNECTION FEES
D. CONSTRUCTUION LIEN LAW (CHAPTER 713, FLORIDA STATUTES, AS AMENDED)
I certify that I, the applicant, have been provided with a copy of "Florida's Construction
lien Law - Homeowner's Protection Guide" prepared by the Florida Department of Agriculture
and Consumer Affairs. If the applicant is someone other that the "owner", I cerify that I
have obtained a copy of the above described document and pronuse in good faith to deliver
it to the "owner" prior to conulIencement.
E. CONTRACTOR'S/OWNER'S AFFIDAVIT
I certify that all the information in this application is accurate and that all work will
be done in compliance with all applicable laws regulating construction, zoning, and land
development.
Application is hereby made to obtain a permit to do work and installation as indicated. I
certify that no work or installation has commenced prior to issuance of a permit and that
all work will be performed to Ineet standards of all laws regulating construction, City
codes, zoning regulations, and land development regulations in the jurisdiction. I also
certify that I understand that the regulations of other governmental agencies may apply to
the intended work, and that it is my responsibility to identify what actions I must take to
be in compliance. Such agencies include but are not limited to: *Department of
Environmental Regulation-Cypress Bayheads, Wetland Areas and Environmentally Sensitive
Lands, Water/Wastewater Treatment
*Southwest Florida Water Management District-Wells, Cypress Bayheads, Wetland Areas,
Altering Watercourses
*Army Corps of Engineers-Seawalls, Docks, Navigable Waterways
*Department of Health & Rehabilitative Services, Environmental Health Unit-Wells,
Wastewater Treatment, Septic Tanks
*U.S. Environmental Protection Agency-Asbestos abatement
I also certify that, if fill material is to be used in Flood Zone "AH or "A,etc.", it is
understood that a drainage plan addressing a "compensating volume" will be subnlitted which
is prepared by a professional engineer registered in the State of Florida .prior to permit
issuance.
A permit issued shall be construed to be a license to proceed with the work and not as
authority to violate, cancel, alter, or set aside any provisions of the technical codes,
nor shall issuance of a perm~it prevent the Building Official from thereafter requiring a
correction of errors in plans, construction, or violations of any code. Every permit
issued shall become invalid unless the work authorized by such permit is commenced within
six months of issuance, or if work authorized by the permit is suspended or abandoned for a
period of six months after the time the work is conunenced. One 90 day extension of time
may be allowed for the permit with fee charge of $15.00. The extension shall be requested
in writing to the Building Official. An approved inspection must be logged during each six
month period, or the project will be considered abandoned.
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 LENDE OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. JOBS UNDER
.2,500 VAL NOT NEED TO RECORD AND POST A "NO~'
SIGNATURE: CONTRACTOR DAVID R. ABLA
. STATE OF FLORIDA
COUNTY OF PASCO
The foregoing instrument was acknowledged
Before me this _ day of 19_
by DAVID R. ABLA
(name of person acknowledged)
~ who is personally known to me, or
STATE OF FLORIDA
COUNTY OF
'l'he foregoing instrument was
Before me this day of
by DAVID R:-ABLA
PASCO
acknowledged
19
(name of person acknowledged)
~ho is personally known to me, or
Name
\Stamped
Owho has produced
(type of identification)
and who Ddi~~oath
Signature of PptiWRA ~~fA~9_ acknowledgment
_.:\';~~ I' !\!ot:i\ If Pl!\JLc" :.~!kth) Ui r
.;'. ;'; I i/I)/ c. "rnd;;;;'ur' L.xoin;s julv ",~ ".
Name typed, pjr.::i!ntJed,rO-l;1 ~ftIF1~d
Owho has produced
(type of identification)
and whoO did J21did not take an oath. .
a4r:x:$44
Signature of per~on taking acknowledgement
U.S. Intec Certified
Platinum Installer
#5204
~
Jro-po-sa!
1
of
3
Pages
(
Member of the Florida
Roollng and Sheet Metal
Association
MilBar Construction Inc.
Roofing. Concrete. Commercial. ResidenZal
15911 US Hwy. 301 North' Dade City, Florida 33523 c::>c
352/567-6047 · 800/562.2393 · FAX: 352/567-4454
State Certified
Builder #CBC023221
State Certified
Roofer #CCC051562
State Registered
Roofer #RCOO55215
RCI Registered
Roof Consultant #0149
PROPOSAL SUBMITTED TO
PHONE
DATE
KURLIN, NANCY
813/783-2420
Joe NAME
03/16/04
STREET
5735 14TH STREET
KURLIN RESIDENCE
CITY. STATE and ZIP CODE
ZEPHYRHILLS. FL 33542
ARCHITECT DATE OF PLANS
JOe LOCATION
5735 14TH STREET
Joe PHONE
ZEPHYRHILLS, FL
We hereby submit speciflC8tions and estimates for:
SHINGLE AND FLAT RE-ROOF
CUoesNoflocIurle '.losulaterl'.'riefaIRoof)
A. SHINGLE ROOFING
1.
Tear off and haul awaY~~l?e)Ci!3tillg thTee-IaY"l?TIIll?~Cil, !3~~llg~E" & wC1od. :r()()~~n~L
systems; clean up work area daily.
2.
...... ...........--..........
.. . ~..~..:.~.i~:....... .:~..~............~.~.:~~:.~..~............::.:..........~...~............~...~..............::~~u~ :~:~.~:~~~:~::.ww.
Prbvide a~d install new TANKO "Elit., ass-Seal AR" 25-year 3-tab algae-resistant
fiberglass shingles; Owner to set shingle color from TANKa's standa;rd
...,.,.,...."................,....-...-.".........,..-----...-....-....".........,.,................'.".....-.--...-.....".......,..,--..._,.....,."...,.........---..."........ .........,.................".."......,...,...,..."..."......,.'''.,..-........,......."...-.-..--.-"......,........'.,...,..."...,..,.........,....-....,................,....-...,.........,..,.....".....-,-...-...."......., ....,--.,
COlOTS. Shingles have a 25-year limited warranty from TAMKO.
..... ,......._-,--'.......--,--.
3.
4.
Replace all damaged
(valley, vent, or any wall flashing).
Provide and install
new
lead boots for the plumbing vents.
6.
:3 ~ I rJP1
Provide and install new pre-finished aluminum ea~ed~.ipe~~~b~~~~).
MilBar Construction, Inc. to provide 5-year warranty on workmanship; ex-
c 1 u s ion s : l:l~()r:11l9~11l?9~!'!()Elt().l"t:l~11l~,9~9()De~Yw()~h~;rl:l! ...~!:~~t:l_~l1lc:lg~L!'lTlQ/g:r-
structural damage to roof deck.
7.
~,t JropOfi,t hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
SEE PAGE THREE. dollars ($ ).
Payment to be made as follows:
Invoiced amounts not paid In accordance with the payment terms shall be considered delin-
quent and bear Interest at the rate of one and one-half percent per month. Owner agrees to
pay all costs Incurred. such as attorney fees, collector fees. court costs, etc., for collection
of delinquent invoices Including Interest. Owner to carry fire, tornado and other necessary
insurance. Our workers are fully covered by Workman's Compensation Insurance.
Authorized
Signature
Note: This proposal may be
withdmwn by us if not accepted within
30
days.
Date of Acceptanoe:
,
~.c.ceptan.c.e of 'mroposal -The above prices, specifications
and conditions are satisarctory and hereby accepted. You are authorized Signature
to do the work as speci!" ed ayment ill be made as outlined above.
Signature
U.S. Intec Certified
Platinum Installer
#5204
~
Jrllpnsa:l
Page No.
.::..
of
:1
Pages
~.
Member 'of the Florida
Roofing and Sheet Metal
AssociatIon
MilBar Construction Inc.
Roofing. Concrete. Commercial . Residen~al
15911 US Hwy. 301 North. Dade City, Florida 33523 c::>c
352/567-6047 · 800/562-2393 · FAX: 352/567-4454
State Certified
Builder #CBC023221
State Certified
Roofer .CCC051562
State Registered
Roofer .RCOO55215
RCI Registered
Roof Consultant 10149
PROPOSAL SUBMITTED TO
PHONE
DATE
KURLIN, NANCY
STREET
813/783-2420
03/16/04
5735 14TH STREET
JOB NAME
KURLIN RESIDENCE
ZEPHYRHILLS, FL 33542
ARCHITECT DATE OF PLANS
JOB LOCATION
5735 14TH STREET
CITY. STATE and ZIP CODE
JOB PHONE
ZEPHYRHILLS, FL
We heraby submit speciflC8tions and estimates for:
B. FLAT ROOFING @ REAR
Rear roof area current.iyhasmetal,shingIe;&voodroof:i.ng~ Bui.IdingCodes require
flat roofinc:Jma~erialsonr()of!3rl?El13wi~hlessthan 2: 12 roof pitch. Therefore, to be
in compliance with current Building Codes, we are quotingaflafroofing system.
1.
'Tear off and dispose oTt.he old t.hree::IayerroofingsysTem:
2.
Provide and mechanic:aIiyfasten "a Firest.one.MB Hberglasshasesheefover 't.he
,p~y!()od deck pri.()I'~()t.hE?i.rls~!3llClt i()fI" of ttleFirl?l3t.()nero()~i.nQ membrane.
3.
Pr,.Cly',i e!E'..,..". Cl fie! ,.",.i.,.J).~,t.,.Cl!!.."""NCl..""."'NJ)"':,!,.,.,,,Y,i.,I::,':13t.,.()"J),.E'..,..",."".~,.,~,,~. :.!..~,~.,.ww!.tl,i.t.E'.. '.'."w\1EClJ),~!E?,:13':lE~,.Cl,.'?,.E?,.,...".".,E() ()."~,.~,f1.~..,,.,.,
membrane which is a torch-applied fully-adhered modified bitumen roof system that
is heat welded at t.hE?l3E?ClID13t.()f():rm()f1E?13hE?et.;Clflci()f~E?I'sCl.~irestone's12:year
"Modified Bitumen Membrane Limited Product Warranty." ' '" ",'" "
4.
All metal and concrete surfaces will be primed with an asphalt base primer prior
, .",...t.(),i.J)13~!'l!!Clt.~9J),()!.t.~E'!:',!EE'13t.gflE',I',()9!!J)9w..'.'1,~'!'~!:Cl!~~~.. . .. .... .........w....
5.
Pr'ov il:lE'...Clrll:l.i:.ns;:t:.El~.1....f1E'~?~ga1l9E' . 9Cll.Yliifl~~el:lIDE't.CllE'El\'E'~Ei:P.. around the
perimeter of the roof as needed.
C. GENERAL CONDITIONS
1. Any rotten or damaged wood deck, fascia, trim, etc. replacement or re-nailing of
t hee)(i.s;~Allg roof deck. ..!~g..b.E'.c:()'.'1P1E':t:E'd....()n....lii.c:()s :t::-plll13b.liis;~13Elb()\'E'....i3J)e! . .bE'y()n~...
the contract price.
~e J1ropose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
SEE PAGE THREE. dollars ($ ).
Payment to be made as follows:
Invoiced amounts not paid In accordance with the payment terms shall be considered delin'
quent and bear Interest at the rate of one and one-half percent per month. Owner agrees to
pay all costs incurred, such as attorney fees, collector fees, court costs, etc., for collection
of delinquent invoices Including interast. Owner to carry fire, tornado and other necessary
insurance. Our workers ara fully covered by Workman's Compensation Insurance.
Authorized
Signature
Note: This proposal may' be
withdrawn by us if not accepted within
30
days.
~.c.c.epbtn.c.e .of 1ttrop.osnl -The above prices, specifications
and conditions are satisf:rctory and hereby accepted. You are authorized Signature
to do the work as specifl~r\~ment will be ~de as ~lIned above.
Date of Acceptance: 'J-..UU./U' V\ L-<\- I "LCJfJ~ Signature
U.S. Intec Certified
Platinum Installer
#5204
JroJiosal
@ MilBar Construction Inc.
Roofing. Concrete. Commercial . Reslden~al
15911 US Hwy. 301 North. Dade City, Florida 33523 <:::>c
352/567-6047 · 800/562-2393 · FAX: 352/567-4454
3
Pages
3
Page No.
of
Member of the Florida
Roofing and Sheet Metal
Association
PROPOSAL SUBMITTED TO
KURLIN, NANCY
STREET
State Certified
Builder #CBC023221
State Certified
Roofer #CCC051562
State Registered
Roofer #RCOO55215
RCI Registered
Roof Consultant #0149
PHONE
DATE
813/783-2420
JOB NAME
03/16/04
5735 14TH STREET
CITY. STATE and ZIP CODE
KURLItt RESIDENCE
JOB LOCATION
ZEPHYRHILLS FL 33542
ARCHITECT
5735 14TH STREET
DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for:
ZEPHYRHILLS, FL
4. .C1!~'l?r~9f':C(JV~~I?E1C1C1I?I::i3.!(J:C .1:f1?~~YI?~:Y,t:cucks to allow rooi~(JEI~i~lg/\l,:,loading
for the entire roof area.
..........'..........,.....,....-..".."........--...." '.--....""......-.....,....--..."...,.........................".'...--..--.....".....-..........-..
Nil Bar Construction, Inc. to provide General Liability and Worker's Compensation
Insurance (..!$?,fl!0flJJ.ifl!~:;~~;Nt;l..~.stt:14CJ!t:J;~...PI?~I11~~~N'3/~'ww"", ..... ..........
OPTIONS .. ........................~...................................................~q..~~u3AL.......... ... ............. .......... ..1..~~rS:.g~<6f'!!~......................... ...................................
1. ShinQle Up-Grade. Provide and install new TANKO "Heritage 30 AR" 30-year
1.a l1linCited ... .di me(\l:liollCila~gCl(?__r(?sistCl~1:fibE?l'91ElselEl~~~g~(?el in lieu of T AMKO
"Elite Glass-Seal AR" 25-year 3-tab fiberglass shingles.
ADD $420.00 to!'!le con:tZ::Cl9!,p:rJ9E?~
.....So;(fit &. Fascia and GutterL. .' ...................w.w~.Ww.w'w..
-Provide and install 42 linear feet of pre-finished aluminum soffit & fascia and
.. gutt~Ls . on....lo\f~~:-~nt..rcmc.~.....ro()f.ollly.
-Owner to select color from standard colors.
-ADD $860.00 to the contract rice.
~t Jropost hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
I ).
dollars ($ :;. QOlfjl 0101
3.
D.
.....~
'-i
~.
\\~
t'v~
.. .L
3.
15
~~0
Attic Access
-Provide and
* P:rovicieClnd
as possible.
...!I.hg......p!:i.c.~..........i.l:l...........!l..Cl.J?E?Q.....O(\w..Cl.w..~!-~m.Q.!=1.!:Q.....<!pp+.i.c.!=1t...i.QI"l.... Q!....c::.~...t..t.i.(\g .ClnQ...,EE?,~!EJ.yi(\g.elh.E?,E?t.!::og~...
ceiling and wood blocking as needed.
.. ... . - "Pi>~t.iIlElt""dC()I:Jt..()tl;lZ~~~~~.t.ot.tl(?c:()Jl:t:r-lilC.:tP:r-:ic::(?
-If additional construction is required, the additional construction will be
.c.QJl.lpl~:t~clClncl bJJ.,,l,E='qQ(\,:1C.9elJ::P,1,\Jel basis in addition to the Estimated Cost.
Ladder ~.....
install a pull-down attic access ladder.
inelt.all t.ril1lmoldi(\9e:lilfH:ip13int to match
.the......(?)(il:lti~9....ael...cJ.,0I3eJ.,y
------ -------- -- - ---
Payment to be made as follows:
Invoiced amounts not paid In accordance with the payment terms shall be considered delln. Authorized
quenl and bear Interest at the rate of one and one-half percent per month. Owner agrees 10 Signature
pay all costs Incurred. such as attorney fees, collector fees, court cosls, elc., for collection
of delinquent Invoices Including Interest. Owner to carry fire, tornado and other necal8llry Note: This proposal may' be
Insurance. Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us If not accepted within
30
days.
j\.c.ctptan.ct of NroposaI -The above prices, specifications
and conJltlons are satis?afctory and hereby accepted. You are authorized
to do the work as spec I . Payment will be made as outlined above.
\ L ' r
Date of Acceptance:
I
Signature
Signature
.
NOTICE OJ? COMMENCEMENT
MCI # 3299
Pemtit No.
Parcel I.D/FOLIO tUI- 1..(0 - ~ 1- DDI 0 - DR::jO{)- nOlo
11111111111111111111111111111111111I111111111111111111111111
2004071872
State of Florida
County of PASCO
Rcpt: 77!5815
DS: 0.00
04/22/04
Rec: 6.00
IT: 0.00
Dpty Clerk
THE UNDERSIGNED hereby give notice that the improvement will
be made to certain real property in accordance with Chapter 713, Florida
Statues, the following information is provided in this notice of
commencement.
JED PITTMAN~ PASCO COUNTY CLERK
04/22/04 110 : 02am 1 of 1
OR BK 5819 PG 728
I.Description of property (kgal description of property and address if available) 5735 14TH STREET
Section II , Township 2h , Ranqe 21 ()/)/I) o/1EtJIJ 0010 ZEPHYRHILLS, FL 33542
2.General description of improvements SHINGLE AND FLAT RE-ROOF.
3.0wner information
a)Name and address (1f\'N~y KUllL(1\) Sl'3::.S 1L{1} ~+. 'ZG?~r2.\"hLlr:. ,~L, ~~'SH0 .
b)lnterest in property 100%
c)Name and address of fee simple titleholder (if other then owner)
4.Contractor (name and address) MILBAR CONSTRUCTION, INC. / David R. Abla
15911 US 301, DADE CITY, FL 33523
5.Surety
a)Name and address
b)Amount of bond
6.Lcnder (name and address)
7.Person within the State of Florida designated by owner upon who "notices or other documents may be served as
provided by Section 713.13( I )(a)(7), Florida Statues.
Name and address
8.In addition to him or herself, owner designates
of to receive a copy of the Lienor's Notice as provided in Section
7 13.13(1 )(b), Florida Statues.
9.Expiration date of notice of conunencement
from the date of recording unless a different date is specified).
(the expiration date is one year
STATE OF FLORIDA
COUNTY OF PASCO
OWNER I S SIGNA'IURE
PRINTED NAME & 'fITLE
-4~I~ ~~.'~l~~
TIle followin instrument was ack.nowledged before me thim.day of~Pb6~, by Nan~ ~hn
who is rsonally:;lmown 0 me or who produced . as identification.
After recording, retu[!! to:
Name MILBAR CONS'rRUCTION, INC.
Address 15911 US, 301 ,'j .;.
City DADE CI'Tyi; --Pf:.. 3-3-5 ~ 3
"". ~
" I'll
APR-22-2004 07:42 PM
P.02
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>>~LlCAT:tOJr I'Ol\ nNCIT
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aUILDlwca D.~AI\'I.'MII:WT
MCI 3299
DAB gal""
PIMa MVIn ....
PARCEL ID ..
SUBDIVISION
OWNER'S NAME
JOB ADDRESS
WORK PROPSED=
o ADDITION
o ALTERA'f I ON
o REPAIR
o INSTALL
I"KUI"USl!:U
o MOVE 0 DEMOLISH (j. ~N0
DMuL'n-JrAMILY 0" Of' UNITS 0 MOBILE HOME
o INDUSTRIAL
o SWIMMING POOL
o OTHER
DESCRIPTION OF
BUILDING SIZE
SQUARE roOTAGE
f\SSIDmNTIAL:
COMMBRCIAL:
,
i
1;(21 PLOT PLAN~ & (2) ~ST~ OF DUILDING ~LANS & (11 SET ENERGY FORMS.
.1 ! (3) SETS OF BUILDING PLANS & (1) SET ENERGY FORMS.
.. SURVET 1\EQUIRI!:D FOR ALL NEW CONSTRUCTION.
'PERMITS REQUESTED
o BUILDING
VALUA'fION OF TOTAL CONSTRUCTION
o ELECTRICAL
. AMP SERVICE
o FLORIDA POWER
o W.R.E.~~
o FLUMBING
o MI!lCHANlCAL
o GAS )J{ ROOFING .
TU'E OF
$ .1 I
, !
VALUATION OF MECHANCIAL INSTALLATION
D OTHER
o t..HAA.Ilt
o ::rn;I!iL
o U..l.I....E~
IS PROJECT IN FLOOD ZONE MEAD YES O. NO
. i
.UILDD , , .. COMPANY:
..
- ,
.' , STATE CERT OR RBGIST It
r
,
SlQNATURE I CITY PROCESSING It
***.******.....................*..*........*.*.*......."'.
BLBCTlUCID
.A<:":~!i~N~TU~~~.,._
. .
'_"_M_._ ..".....~H ..
COMPANY. ,
STATE CERT OR REGIST #
. __.._...... .,...._ C.!~.!. P.~g~E~~~tI.~__.~_ .. "
~~-.ll~' H
H ~_ "
*..**
: " ..,: . .
:~..*.* "'. *,***..... .'...."'.. ...... ... tIl-*......* .**...". .'... *...."..
i 'i~"':" . . ".. ' .'
. \-
~LVM8IIR
SIGNATURE
i ,
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COMPANY
STATE CERT OR REGIST ff
CITY PROCESSING *
.............
I .
! ;
I ,
t: ..~.~.............................*...*.***..*..."........
_CIlARICAL
: I
COMPANY-
STATE CERT OR REGIST *
CITY PROCESSING "-
SIGNATURE
I .
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! :
I. .
. .
..... .' .....*......................*."..".........................*
, . ,
SIGNATURE
,"'.;,' I ,. .
..*;".,,' '., ...".".".... .... ........... .... * ..." **..... ...."........". ... ......
,
COMPANY MILBl\R ~crlOO, INC.
STATE CERT OR REGIST # COC 051562
CITY PROCESSING" 218~ '.
OTBJ\
APR-22-2004 07:44 PM
'. I J
I CONDITIONS OF PERMIT AFFIDAVIT
A. NOTICE OF nRR ~'t'RtC'J'tONS
Th. under.iqned u standa that this pe~t may be subject to ~deed restrictions" which
may be more restrve than City regulations. The undersigned as.ume. responsibility for
eomplianc. with applicable deed restrictions.
B. UNLICENSED CO CTORS AND CONTRACTOR RESPONSIBILITIES
If the ownef has~ d a contractor or contractprs to u~dertake wo~k.theymay be required
to be licensed. In. ardance with state and local regulations. If the contractor 1s not
licensed as requi by 1,.,.." both the owner and contractor may be cited fOIr 'a misdemeanor
violation under s .,\ 'law. If the owner or intended contractor are uncertain as to what
licensing requir . may apply for the intended work, they are advised to contact the
City of Zephyrhil : uilding Department, 813-788-6611. ,
Furthermore, if t I wner ha.'hired a cont~.ctor or contracto~.,he 1s advised to have the
eontraetor(s) s1g : rtions of the ~Contract~r SectionsM of this application for which they
will be responsib~i If you, asth. owner signs 8S the contractor, you are indicating that
yuu, c.l.heu: LInin 1 .; l;UUl.LUl;!.;O.a:, Cl.a:e .r:elllpona1.bl.e fOI: the wOl:k. If the contJ:actoJ: wi_hilUS
you to 81gn as .co '.' ~etor ,.tl}.at may be an indication that he 1s not properly licensed and is
not entitled top . "tting privileges 1n the City of Zephyrhills.. .
C. TRANSPORTATIO PACT FEES ~D UTILITY CONNECTION FEES
D. CONSTRUCTUION IN LAW (CHAPTER 713, FLORIDA STATUTES, AS AMENDED)
I certify that I, :~ applicant, have been provided with a copy of -Florida's Construction
lien Law - Homeew ' ':' s Protection GuideN prepared by the Florida Department of Agriculture
and Consumer Afta k: .:. If the app1.1cant 1s 8omeone' other that the "owner", I cer1.ry that I
have obtained a c i t of the above described document and promise in good faith to deliver
it to the ~ownerN .j or to commencement. .
E. CONTJUl..CTOR' 51 R' 9 AFrIPAVIT
I ..
I certify that a1 ! ~e infor~tiQn ~~ this application 1s accurate and that all work will
be done in compli Pi' with all applicable laws regulating construction, zoning, and land
developmen t. i i.
Application i. he~' made to 9btain a permit to do work and installation a. indicated. I
certify that no ~ ~ ' or installation has commenced prior, to issuance of a permit and that
all work will be . ~ I .formed to meet standards of all law. regulating eon.truct1on, City
codes, zoning reg ~.tions, and land development ~egulMtions in tho juri3diction. I alao
certify that I un ~ :.stand that the regulations of other governmental agencies may apply to
the intended work I nd that it i8 my responsibility to identify what actions I must take to
be in compliance. j '\lch agencies include but are not limited to: .*Department of
Environmental Reg ~'tion-Cypress Bayheads, Wetland Areas and Environmentally Sensitive
Lands, Water/Wast w:'ter Treatment
"'Southwest Florid: . .atar Manaqement District-Wells, Cypress Bayheads, Wetland AJ:eas,
A!.telo:J.l1g Wcltl1:J:COU :s \ III .
, "
*Army Corps of En ,i.::eers-Seawalls, Docks, Navigable Waterways
*Department ot He :1 'h , Rehabilitative SerVices, Environmental Health Unit-Wells,
Wastewater Treat' ., Septic Tank.
*U.s. Environment ili:Protection Aqency-Asbestos abatement
, ,.
I also certify .th ,tiff fill material is to be used in Flood Zone "A" or "A,etc.", it is
understood that a ~: ainage plan addressing a "compe~~atinq volume" will be submitted which
1S prepared by a :r;:fess1onal eng1neer registered ~h the State o~ Florida prior to permit
issuance. , I .
A permit is.ued . ia'l be cons~.rued to be a license to proceed with the work and not as
Au~hority to ViOl~::, cancel, alter. or set aside any provisions o~ the technioal oodes,
nor shall issuanc, 'f a permit prevent the Building Official from thereafter requiring a
correction of err.:r in plans, construction, or violations of any code. Every pennit
issued shall beco : i,invalid unle.. the work authorized by such permit 1s commenced within
six months of i... '.,ee, or if work authorized by the permit is suspended or abandoned for a
period of six mon . after the time the work is commenced. One 90 day extension of t~e
may be allowed fo' :he permit with tee charge of $15.00. The extension shall be ~equest.d
ilt wl:i.~!n9 to the' :8: :ild.ing O:ff.iciDl. An QPp.roved inspection D\Uat be logged du:a:1.ng each llI1.x
month period, or :h' project will be considered abandoned.
WARNING TO OWNER: i . OUR FAILU~E TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICI!: FOR H ROVEHENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDIR : :R:', ATTORNEY BEFORE RECORJ}ING YOUR NOTICE OF COMMENCEMENT. JOBS UNDER
$2,500 IN VALUE '" T NEED TO RtCORD AND POST A "NOTICE MM_, ENTM.
L.,;L.. ..,'....,....-....,,'. ., ......... .- .,',," .. ..~_. ...,.
P.03
. \
.;0 ABLA
. ;
I
STATE or FLORlnA. .~. :,
COUNTY OF . . CO
The foregoing in.. r" ent was acknowledged
8erore me this I . : :day ot ~r'" , ~~
by ".
'laf (name of per. '0: acknowledged)
JA'- who i R (lfi'lr5l0hJl h". knnwn t-.n mA, nr
[ '1
CJ who has produc 'd~ i
.! ' type of 1d!Bntification)
d Idi!not take an oath. -
STATE OF FLORIDA
COUNTY OF
The:tore~oing instrument w~knowledged
8etore me thJ.1!J ...z....L..day of , n4lVr
by DAVID R~
~ (name of person acknowledqed)
~ho 18 p~r8onally known to me, or
PASCO
acknowledg_nt
Owho has produced
(type of identification)
and who Dd~:., ~id ~~t.,.take an oath
~..."-.
3ignatu~e of peJ:~on taking acknowledgment
Name
:'.1;,.
OLIVIA A. Lov\':n
! b~rSt't
n My COmml&9lon eXplffll JU ze, :!OO-l
Commission No. C0954594 .
" Mtm..-d
'. n EllplrQs July 28, 2604
n: 0.OCH4H4
.! :i
Name tvp~'_
APR-22-2004 07:45 PM
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PtaUnunt : I
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Jr.ttpnsal "
~ Mil~_~!!~.2!!~lnc. .
15911 US Hwy.301 North. Dade CIty, FlorIda 33523 C>c
352/567-6047 · 8001582-2393 · FAX: 3521567-4454
1
3
P-oee
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d
..... cet1IfIM
......... tcBCf.lUlI
..... CIrtlfted
RoofwtcCCOl,.
..... ,...11'1_
JIoGIlIr IRCOOII21I
RCI Rl....'1I1C1
Roof COneubnt 10141
lONE
Mn!.
KURLIN, NANCY
8TRI!ET
5735 14TH STRE
crTY. 81\lII'E 8ftd D' CODe
ZEPHYRHILLS,
MCHlTE(;T
FL i
i ;!
i
3542
813/1&3~242e
.lO8 tWoI!!
KURLIR RESIDENCE
JOB I..OCRJON .
5733 14TH STREET
03/16/14
!l,
!;
DIVE (7 PLAN8
JOI~
2EPHYRHILLS. FL
We ~ III1IImII
tw:
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!.... .t"
_SHINGLE AND FLAT RE-1tODF . '. . ...
(Olll!.' lot. IDOIUCIeT....1.tect-IIR.1 li'O'fr---------
". ".!...:..,;...,...,.,.
! !.
"";.'".........................."...................................................."........."".,.".,."......................................-..................."..............'''"..''...,.,.....,..
'1
A.
1. .~_~...!!:~l .._!l._t_~e_!~i.~~~.....~.~!'..!!.:l.l.!:.....~~_!!! _.shingle.l.....~._!Qod t:'o~fi~
cl..n up work area daily.
. i '. "... .... ....... .... .... '................_............................... .............. ...... ....... ........._.... ......" ".... ,.w', ...... ...... ........_.......... ......,.......................... ......... ..... ............... ..........._................. ....... ..,....." ".................... ...........
:: Pr . ii, - 1_.11 new 15 Ib"! ..~t....t.ed :1t ..._"
______l~:1:~.~..:i~7" ;~=~~~~ _ ~1~~Ii.O~:;..~,,~to~.~~~~;l:.-:::
001; . Shingles have a 2S-y..r M1ted warr.nty frOM TAKKO.
[
--i:-.-"......R.p.- --'-err-d...ged fl..hing.-..rv.1I;y;-y.nt~~.or'..ny..-w.n :flashing).
, ~,
5. PrD :i~' .nd in.tall Mn;;;- le-adb'Oots for the- P1U.bing-v;ntS:-~ a' fJVC1 --
.....................,...........6':................~Q 'i;.....iind...ln.t:.Ii""..n;;.'...pr.=iini.il;(f...al"u.inu......av4!dr.ip...~.oi.....b;:o.;n.)..:.......,....................
,I
---.',,,-...--. 7 . ---Mil .. Const.ruc:t.ion:-Inc:-'toprovide -S-=ynr-'nrranty.'on--;ork..nehi P J ex ':--..-.-..-'-
""_'M"'~_,____,_ c.l 'f nBS ~orM d...get..._.!'..2.f~.....QL9!!!Y. doft. b.l... oth!!,.!I.t. t.r.. da.ag.~ and/or
&tr.. ,.ural d..age-to roof deck';
..................-.... ............ ......,................................ . ..: r............-..,...... ..................... ._............ ....... ........ ......................... ....... ....... ......, ...................................\,.. ............." ".,,', "., .........,... ......."....,...... ............................................. ...................................., ....... ..... "................. "...
i ~
.:
~ JrPpJJJe I:"
SEE PAGE TNI . I
~1o"mllde.
I
to furnish material and labor - complete In accordance with above specIfiCatIons, for the sum of:
dCII\aN ($ ).
IrMIIoed .... naI p_Un
.-nt Mod ~.,.,.. ......
~ .. _1ncllI'NcI. IUCI'I .
d """1rMIIc8I
Ir---. 0.........
will lie,.............. be~ d8IIn-
.- - -..MII.--. per--*,. 0--.-..
,.... coIIIaIDr..... ~ ~ &. fllr ooIIIclIIon
Owner \0 CIIIWY'" klmlIdo lIl'ld .... '*-Ie/)'
brWorlarwra CClI'''I*~ lnMnnoe.
AuIhorlzltd
~
Noee: TNa IlRlDOIIlIllll\V be
~ byua. noi~ wIIhIn
30
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.~d~;; ad
to do the WIIIk _
DIlle of ~..
SIgnature
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~'
APR-22-2004 07:46 PM
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P.05
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15911 US Hwy. 301 NOr1h. oaae CIty, FIorlCIa 33523 C>
3521567-6047 · 8001562-2393 · FAX: 352f587-4454
P.o- No..
2
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3
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U.$.1DI8O
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..... CIrtIIIecI
1uIIdIr~..fJ
__ c:.rtIfIlId
RooIIr 1CCCOI1.
..... ......lIIM
IIIoofIII' .RCClGIII1.
RCI ....11111 tel
Roof eor.un.nt.....
l5UIIMf1"Ta) TO
,
,I
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813/783-2420
JOIIIUMI
IURLIN RESIDENCE
0108 LOCATIClN
~73~ 14TH STREET
03/16/14
KURLIN, HANCY
8TAIE1' I
. 5735 14TH STRf:1 .
em: STA11! 8nd 'ZJff' CODE .
ZEPHYRHILLS, FL i "3542
AACHrTECT
DIlFE OF PI.AH8
JCl8 PHONI!
ZEPHYRHILLS, F'L
W6 hetoby oubrnIt
....-.- tor:
_e. .1tBAIl. .. .
'. ".'1" r.~ ,.. aU1"'t'..nUy h..-.;:t:.l. .hingl.;-&'wo-od roo~liftg:- LildinG Clli~!'Oq "
flat roof l. ..terials on roo! ere.. with 1... than 2:12 roof pitch. Therefore, to be
'.....-.......-........"'.In.....co.P!l !-'. ..........vIH1....c\..rr.nt...BuildIng.....COd"~-.....w...".i.""q\ioti"n'g"'8""fla't""'roof1"rigm"8y'.t..'~".........."......
I :1
I ' ff .ncf'di.pORof-thi" old-t.hrM-lay.r-roofing sYst.a:-'-------------
,l :
--'---~-"---'P;:e:'1 .--...iid-...IeC.il.ii1"c.l'l'y.."i..."ieo........"F:Lre.to.n-.-lijr..t1bi'i-glais base ebMt. OV~ t. .
"........,......-,-.,..,.'''..._......,.._...P.!, .. . ' .~L.~~,~.....p.!.!~!:._~~,...~.~,!.,.,~.~.!~.!!_~.~.~~..~.~.,..~.!.....!:.~!.....~.~~!~.!:~~_!._,:r._~_~~.~!!f.__.~_~~~.~~!~..._....._....._...._
i :'
3. PI" : If and inst.all 8 new Firestone APP~lee whit.e Rranule-8ur:fao~~:f1ni
.... . n. which i. . torch-appliR fully-.dh.~ .odi:fied bi tu..n roof 1I)'.t... that
I .
_..,......_,.__..........--,......-..._,.~~- ".. 1;_!~~_c!~..~!_~~~_.~.~~....~9.....~9.r.1,!l....~~!._~llltet. J _~bd rl!.~;f~..!..J:~~ton!.:~. 12:lear
.. : ied Bitu..n "..brane Li.ited Product Varranty..
I :1
I
-~---Ail: ..1 .'nd C1DftClrttt.. .ur:f";;;;-';i"iTb;---p;'-:liOd-';ith"-an'uph.i~-b."i.;-.'pr[_r-pJ":lor'~
to . ~ t.llatioR 01 the Fire8tone r~.!!Q...!!t.bran...
~ .. l'
I' .
_..-....__...__...,...-.._..~!......_._....__.~!? .~~ -!..-!~~....~~!.!.!...~..!.._.~~.....g~~.g.!..._g.!.!!.~.~.!~~...~~.!.;'....~!.Y~~,~P...!!.~~~~...,,:.t:.~,!..,,_,....._."'....,.....,...,__..
per .1' of t~ roof as needed.
---------..--'.......-~...,.-.._.......,..--'''''''"_..._......'''".......'_...,..,_.........,,,Ww....,.......'"""_w........--.,_...........__......,'.........,.._...........__......___--......__~...."......__.....,...""..'M
'.......---...................--..--
'. !. .. --oJ..... tten-br "da'MaCied wood deck, 1'aacs1a, trt., etc.. NPlace..nt or re-na;LUag ot.
. ...._.-..-.--_............-....._....-...---....~-' :!..-. ~-~.~.~g....,r.~.~.='-._..g~~....!~.!..J.......~...~~.'!I.P~.~~.~....~~.....~......~,~!:!=:.::::p.,~.!:!!....,~!.!!!.....!.~.~!.!,....!.m~.....,!!y..9.~~.....
the- ! ntraot prioe.
r '
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IrMII8ecIII'IICU'llI flOt _ ... I
C1UIflt IInd .... ~.... .
PIlr .. CIOID 1ncuNcI. IUCItI .
cI~ Inldoee
---. Our.,....
to furnish material and labor - complete In accordance with abOve 8peclf1catjona, for the sum or:
dol.. (t ).
...........".."..... be ~ deIIn- Authortzed
' ON Md -.w D8lllInt... monIh. Owner __ to S!gnatuNo _. ____
..... ............ out -. ... fDr GGIIIaIIon
Owner to CllIny lh. tDrMCIo n other 1le(1" J ry Nal8: ThIs pmpaetII "'-Y be
tJ,~ CoqIeJlIlolIMIlnuw1cI. wlIhdIawn by... not~ wIIhln
38
.l. ~r7n"n'J"e Df
~d~;;;;=..
to do ..... wortt as
SIgnature
Drdeof~
SIgnature
. .'
I.'
APR-22-2004 07:48 PM
P.06
.......'01 III .
Aooftnt ..
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'ropuBal
~ MII~.~.~L~L.lnC.
15911 US Hwy.301 North · Dade ~ Florida 33623 C>
3521587<<>47 · 8001582-2393 · FAX: 3521567-4454
Page No.
:)
t:A
3
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"
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"-tInum
fII04
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.... CIrWIM
BuIlder ICICMMa1
.... c.ratIed
RoofwCCCOl1111
..... ..........
IIooW IRC8a&II1I
ReI A'.'''.,"
Roof eon.an.nt.....
; ~
KURLIN NANCY.
8TI&'l'
. . 5735 14TH STRE
aTY. $WI! Ind Z1P~
ZEPHYRHILLS
AACHmiCT
. ~
:!
PHONE
~ I
813/7sa-242e
JOII NAME
83/16/84
KURLIN RESIDENCE
.IOD LOORION
5735 14TH STREET
.lO8~
We ""*' MrnII
ZEPHYRHIl.LS FL
.. ,. O!:i.~~_tQl' d.!!!!!.!!'y ~_UC"R. t.a ..Uo.. :r.?M 1!)ad1I\Clhanl~:l.ng... .__
Itntire roof 81:'&8.
'1
"
3. Construct.ion. Inc. to provid. Bltner.l LiabUit,y .tIld Worker'sa Co.pen...t::L'o'n'"
..'-._-_..~...., :' ce (.2.1.~7 11~~,~~d f!:i!!-~!-~ftt.it:...,_._~__,_,__,._.__,_,__._
..J). ... ...PPTIOIS ~~____ I : i_...____'____._.__...~~__.:..___q_.~'!:~ ~.k.L_~-~.......-._--~~-~~~5~ ______._.___
1."" - rd. Provide and install n." 11&"KO ItH.ritagtt 38 Aft- 3t-ynr'
~,."_._".,,.,.,tii- 'c. !'~;~~=i;?f"~i~~"'2~~.:::;~j!t-:h~.~tb!r~i;.gs~'~i';;~~~~!~tm'!!\.--...!.~.~..._,~.!,w",!~~~9..._
. I .
~.. to t.b. contrac~ ~r1(le.t.__.. __'__._ ____
~_'''''''''''''''''''''''''''''''''''''~'M''_-'''_''''''''-""""____"""""",_,___,,,,,,,,,,,,,,,,,,-,,,,,,,,,"""'^""._........._._.......__ .. .....,.,...-..,....._....--..............-
and install a pull-down attic ac~s. l.dder.
~I.~~,l~.... tri,!._.!!.~:l:~in.5l!.....~~~.....P.!!.~~......t-~,.!8~9.~....!h!....!xil!.t~~_~~~~.~!!!,r..
sible.
g~ ~. bll'ln QA...I .t'''~.Jrd._appl1cat.iB!L9.f cutting and r..ovinS sbeetrack
9 and wood 'blocking as n..aed.
. ..t.ed.....Co8t-...Af....I1.'-tI.........tQ..,:U,.....~~.....K.~~~".,.....,""....,,..,....__....__.....___.............................__..........._........-..._,"
. itional construction 18 r.quiredt the additional construction "ill be
~-..J-ng--b..U.-J..!tcLmLL..Q.Ql.bl~@._..~.jti@.J,lL._adl!!lli.!t_'!;..~_....~~!'t_EIIt1_t.._l!.,f:~_~~_
'......-.....---................-.......,.....--...-.......-.........
-and inatall 42 Hneer f..t of pre-fint.hed alu.inu. sof:fit & f.sciL.,....d
... ..... ........... ,.............--................... ......, ,..... ............., ,........... ..,......-................ ......... ............................ ,.....,
to furnish material and labor - complete In illCCOrdiInc;e wlth IIbov8 specIfIcaUone, tor the sum of:
------------------------- doIara($ ~J QDlDl la9 ).
--- ~OlOtp8ld....
quent 8nd beM'rrw..t....
pay .. ClO8la Inourred. euatl_
01 dllInquerIt .....1rIclIudInQ
~0ur---"1UIl!
wIlh ... .............. ... be cOflIIJ... ....
Ml-.... percent Perl'llGnt1. Owner ~ 10
..... ClIIllce8r..... court ... .., _ ooIlealIon
Owner 10 0My 1M, eam.dllllnd Oltler '*-8IY
brW'l:lll~,_'" eon..lMIIcwllnllaMc8.
Aulhoriqd
SIgnature
Note: ThIa PRlIlOMI nl8y b8
wIItlG...., bv..1 not ~ wIbn
30
ll'1"Md)ft1'.-.llf
~~=ntI.
to do the WCIIk ..
SIgnature
S/gnatu,.
~. :: ~:'