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HomeMy WebLinkAbout04-3529 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813)780-0020 BUILDING PERMIT 3529 Permit Number: 3529 Permit Type: RE-ROOF Class of Work: ROOF REPLACEMENT Proposed Use: NOT APPLICABLE Square Feet: Est, Value: Improv, Cost: 2,487.00 Date Issued: 10/29/2004 Total Fees: 45.00 Amount Paid: 45.00 Date Paid: 10/29/2004 Work Desc: RE-ROOF Address: 5206 10TH ST ZEPHYRHILLS, FL. Township: Range: Book: Lot(s): Block: Section: Subdivision: CITY OF ZEPHYRHILLS Parcel Number: 11-26-21-0010-19500-0110 Name: SMITH, MARGARET Address: 5206 10TH ST ZEPHYRHILLS, FL. 33542 Phone: REINSPECTlON 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: Your failure to record a notice of commencement may result in your paying twice for improvements to your property. If you intend to obtain financing, consult with your lender or an attorney before recording your notice of commencement." Complete Plans, Specifications and Fee Must Accompany Application, All work shall be performed in accordance with City Codes and Ordinances NO OCCUPANCY BEFORE C.O. ~. CONTRACTOR SIGNATURE PERMIT OFFI CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER FROM :MILBAR FAX NO, :3525674454 Oct, 29 2004 .,~7: 57AM P5 :'~, -' ,Mg~LjLlf?, . ' :~,: ,l: ~'1 (:;. ,.", \,..,: , APPLtCATIOR ~ORP~T ". . CI'R 01' DPJllIUIlLL8 8UILDlltG'DD~ .! " , ,~'DM'B:MCII~" ' PLMS,RBVI&" Fa:. ';' .: ,. I.: '.. . .1~' . : ~ . .. .~ .~/ l' :.'1 . ~ . . "i. .. WORK PROPSED: DNEW:CONSTRUCTION: 0 ADDITION ".(. ... PI:\.LTEAATION o REPAIR, ' o INST~L \ . , .',,' '0 DEMOLI SII ' c~' ',' PROl'OSED BUILDING SIZE " DINDUSTRIAL ' . ~ . '" ... ,. .:t : ;'.',: . , , ' , 0 RESTAURANT & HEI\L'fH'DEl'ARTHENT APPROVAL ShJ~'/iio.~.~. ...... ... ..... SQUARE rooTAGE'15()() , . .: ~. , ' CJ SWUtHING ,)?OOL " 0 MOB~LE'''~ME o 9THER, ~ '.. ~ DESCRIPTION OF WORK , . '. I . ~ : Jj' ," : , HEIGHT RESIDENTIAL: COMMERCIAL: ATTACH (2) PL01' PLANs'Ii (2) SETS OF, BUILDING PLANS" & (1) S~'I;,ENERGY FORMS, ATTACH (3) SETS OF BUILDING PLANS, 11) SET ENERGY FORMS, PROPER'rY SURVEY REQUIRED FOR.ALL NEW 'CONSTRUCTION.' ,,' '. . . .. . ." . . " ~ . . , o BUILDING o ELECTRICAL o PLUMBING o MECIWUCAL $ $ ~4Ch1' ,~PERMITS REQUESTED .! VALUATION OF TOTAL CONSTRUCTION . ,~.:;' ---'\ ..~.,.., , AM~, SERVICE . . j' ~, -.-, o W.R, I!: '7'/ //'-<""" ... VALUATION OF MECllANCIAL IN'~~ION i~/i!/; /'1,' " . ,~c ~ I '. o FLORIDA POWER o GAS ,P(ROOFING o SPECIALTY" ..O"O'rHER TYPE OF CONSTRl1C'nON: 0 BLOCR;D FRAME o s'rEEL" o OTJiER ." .... FINISHED FLOOR ELEVATIONS IS PROJECT IN FLOOD : ZONE 'AREAD YES . 0 NO ,t. ~.: .' .. '~' f '\.' . iJH1mi~ii~i~i'i%r:i~1;rrRmi;mWITl;:iW~:tm:0m:~;;)!'-;- - -- - '7: ~--';'. ~~': J ,:,', 'i~~:~i1L~;r,:!:::!:~>~n~:;~W~~fj~1illTI'I:!;:;:H:;;jE!~;;;i'::;~~;;, m"I'~"" "r,I.."", , "t..I....t~I', ,.~,,,',,i.j,.I..'I.t... ",..,./"..0. . "'''1 I ,1....,1, .. .1.,..., ,I '1',,,,1 '.hl,."....,.!!L 'III;;....', ~II" '."1....'....' HI'~ ' ...U,!""i~::~,:IJ;;;::::,,:~: .:E!::::'I:!~l;':;':':::::.!:1' '::;::;',d,:,',:1 ::!i:',:'::" , '::""c. ;:1,:::: :I.:''':::!,. : :::-"::"..:j~!,;;" ;:,':;:..:,:,'"1,),:,,.. ::~T:','.:,!;~ " , -, . ~ I ,~ .' BU1.LbBR . .. . .. ~ .' . COMl'Atfi'..' ' ., , .. , S'l'.I\:TE "~ER'l'~OR,REGI~T it CITY PROCESSING # " , . 1..1: . I . '.' .........4.. 'I.. ~" ". , : ..'{ SIGNATURE ... ' ~. .,. . ~ .' .., . - , .",.. *.* *..* **.. "'...**.. ................... **,'" ****", *'!' .**",.,.****** **.:*~* * *",*'" , . - '.. : ....., . :.... .' . ., . .' .~ ~ ~ . , , . :1." :. SIGNATURE . t:, . COMPANY. ", . i .... STATE :CERT . OR REGJ;ST; Ifi " CITY PROCESSING f# ,." " " ELRCmICIAN . . ..... ..' ~ :...., . -: '. '. '. . --.-',. ,".-- '-"*-***,;;***~*",,,*;'''**''''~~;-*'*~;'..'*-*;***-';;UH'***.-.-.ii'i.;,......-;;-...;.","j.*:....-..-..f' ',~ -. ....-- -- ... ...:- MIlCIlARICAL . ,....... ~ . .:. ~ I ..... . i. . .. . . . '. \.~ ,.. ". '.' r. .. : . *......* 41 ****,.***.. *... .,-. * *...***...... * * **... * ~* * *..", ** *..**. **t*., t"~~*",* *.... COMPANY STATE CERT OR REGIS'.l' If ", CITY PROCESSI~~ " '-~'~'.:. ~-. , . ;"; f'~~.'.._........ PLUMB_ ~ ": . :' SIGNATURE "! : ..tI ," COMPANY- STATE "CERT" OR ,REGIST:-'': CITY PROCESSING, If' '. , '; . SIGNATl1RE '.r., 01'HER "fl""''''.. t *.", "". "*' fl. .....".... ~ ',... ... fl.....,... ......", 4,*....'" ***"'... *", ~.. I, , ; :; ~." ...; ..... COM.PANyMILBAR~Sl'RUCl'I~ I INC. STATE CER'l' OR REGIST# a::c 051562 CITY PROCESSING ~ 218 SIGNATURE . it.. u..*" **..",.. **.*" u'*"::~:~,,l,~* *... * ** **.. * *..... ....**..",.... *.. **....,~.,~,...~,~'" . /',. \'/"',J;..;:., i .' ;" li) ".::>:, ',' <:.;,?<:f} , ':': i:'~':<."'i'. .' .: .'.,.1. .' . .",~ .~. . ~. .' '" ". ..:. '~.:~.~t.:.~..f., FROM :MILBRR FRX NO, :3525674454 Oct, 29 2004 08:03RM Pi CONDITIONS OF PERMIT AFFIDAVIT A,NOTICEOF'DEED RESTRICTIONS The undexsigned understands that this pe~tD~y 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 owner 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 law, both. the owner and contractor may be cited for a ~sdemeanor violation under state law, If the o~er or intended contractor are uncertain as to what licensing requirements may apply for the in,tendedw:ork, they are advised to contact the City of Zephyrhills, Building Department, 813-788-6611. " FurtheDmore, if the owner has hired a contractor or contractors, he is advised to have the contractor (s) sign portions o,f ~b. "Contractor Sections" of this application" for which they w11l be responsible. If you,. as the owner signs as the contractor, you are indicating that you, rather than ~he 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 STATUTE~, AS AMENDED) I certify that I, the applicant, have been provided with a copy of "Flo~l~a'$ Construction lien Law -Homeowner's Protection Guide" p~epared by the Florida Department of Agricultu~e and Consumer Affairs, If the applicant is someone other that the nowner", I cerify that I have obtained a copy of the above described document and promise in good faith to deliver it to the ~owner" prior to commencement, E, CONTRACTOR' S/OWNER' S AFFIDAVIT., I certify that all the informat10n in this application is accurate and that all work will be done 1n compliance with all applicable laws regulating construction, zoning, and 'land development " Application is hereby made, to obtain' a peJ:mit to do work' and, installation, as ind1cate,d '. ,I certify that no ~ork or installation has commenced prior to issuance of aper.mit and that all work will be, perfor.med to meet 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 o.ther governmental agencies may apply to the intended work, and that it is my respons:tb1l1ty',~o identify what actions I must take to be in compliance, Such agencies include but are ~pt'limited to: *Department of Environmental Regu1ation-Cyp~ess, 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 use~ in Flood Zone ~A" or ~A,etc,", it is understood that a drainage plan addressing a "compensating volume" will be submitted which is prepared by a professional engineer registered in the State of Florida priort~ 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 permit prevent the Building Official from thereafter requiring a correction of errors in plans, construction, or violations of any code. Every permit issued shall become 1nva~1d unless the work authorized by such per~t ls 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 commenced. 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 ab~ndoned, WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE:,OF CO~CEMENT MAY RESULT IN YOUR PAYING TWICE tOft IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR ATTORNEY BEFORE RECORDING YOUR NOTICE OF CO CEMENT. JOB,S UNDER $2,590 IN v. UE D N T NEEDT~: RECORD AND POST A "NOTICE CO C .-....-_. STATE OF FLORIDA~ COUNTY OF " ~ The foregoing instrument was Before me this day of by acknowledged , 19-:...- " (name of person acknowledged) ~h~ is personally known to me, Or O'Who has produced , (type of identification) and wh::~k. an-oath . S1:;:~j t'~=~~O"ledgment Name~~~ .f' .... Signature of , g acknowledgement N.me type FROM :M}LBAR lOJ1S/2a04 13:46 i. . . I. ". FAX NO. :3525674454 Oct. 29 2004 08:00AM P2 PAGE: , "1 1 B1368224El6, ,'...... .. . ~. lM1L.8FlR :: F~ NO- ",.'M " .. . ',';'~ 'ropo, ...fI~.~~""- \. <:," UI-301Nofi!l'~ClIIJ'*."~ ~. ,'..,.iU7' . ........2313 · FAX:"'~ i. ...;~.:,., ..' . ~. rr ,II " I' \1 i \ Sltt1&, ..&l1T ! SZe618T'~" \~'''''~.-it.ta,~''''.a ,~ l..,.,..1'IIm \\~ ~'_ ',' , ,....a _ ..,.SUA ~_~.u_.,",...} ".,------- I' .. . '. 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' , ~II ... ."....0".., ..,.,. . 11 '..--:.... ...,..,... ,,- ..'--:......., ~~~- i! \;:~ QItlIeI .1 ~ _, ~ ''''''11I _=-~ " '-.. _....._._..~.~..~....- l..:l ,~... ~ - - ' // _ _";::o_~n .,-.-1",: ~. . 11-" .....;. --....... ,,~~.~~~~ .... u.a.... ...... .............., , .... ' ": ....., ~.".~ ;"i-< .' :., ~. " -J1I _1DIICt' , ::..~. ~' ""M; .. .. ~..t.. . f~' .': .: .~~, ..~.'. (:;;.t:. ;. ~,..'" ..., "1-\>~;' ~:.. . ,': '.~ . .:~ F:ROM : M} LEAR _J0/1512Sa4 FAX NO. :3525674454 Oct. 29 2004 08:01AM P3 PAGE a:2 13:45 1S136<J:221l1ilE. . ~~7 e.. &MII-~.~'"" I IV'. ...-........ . - !I \' .\, . .111'. lIMP,,,," ., , .1" ~ I ~ mil. aTIICTH II -msm.1A r1. ~ .. l.nl iTlm . ;\ 1\ I ~ .' . ZI~U." ft. . ~~ _ ___ --:",J r""~''''''~~~ ..~.. ~'. . t.~ for 1Oa4i.aG.'.R1oalli.. ,.. I'.~~" ~1\ ~ ... "-- \0 ._~. ___" ...oe fer _11.'1"'" _W__-..d-...-...-----.~-.-..,--.. , . ... 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' . . rr ~!!:i.~==~-~~'" .' . ji ............ ..~.......~...INM...OIJIIniG ...~.~~. . l~~ 0...........: ;/1.) - 1.~.~aiY ......_'4~~ ,- .:.' -.. .;.... - .:....... .-... .- .-.... etr.JI '.. :1 \ dirt- T~ ~ ~ on {-. ~: ... . H . .' . ..IJ;.;,"". I....:"":....,;; ....... ~:.:.: '-;;;'" . APPLICATION FOR PERMIT CITY OF ZEPHYRHILLS BUILDING DEPARTMENT MCI 3Lj L/ S DATE RECEIVED PLANS REVIEK FEE O~ER'S NAM~~om~q{1~ . P"ONERJ.t7~~O;}}' JOB ADDRESS___ t;h__":b_Zq>h'fl.hJ.D~ F-'-. ~_y-'_ LEGAL DESCRIPTION: LOT(S) ~) flnd, l~ BLOCK lC1 S SUBDIVISION C-Ct, IJ PARCEL ID f# U-alLh;<I-r:>lJlO-,qSO{) - C1/ {() (OBTAIN WORK PROPSED: [JNEW CONSTRUCTION [JADDITION [JALTERATION [J REPAIR [J INSTALL [J SIGN [J MOVE [J DEMOLISH ~oo~ "' PROPOSED USE:)1fSGL FAMILY DWELLING, DMULTI-FAMILY [J COMMERCIAL [J INDUSTRIAL ! [Jf# OF UNITS . D SWIMMING POOL [J MOBILE HOME DOTHER DESCRIPTION OF WORK c:J RESTAURANT & HEALTH DEPARTMENT.APPROVAL sruno/-J- Ifo -IZKJ& SQUARE FOOTAGE.15fJD HEIGHT BUILDING SIZE 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 [J ELECTRICAL [J PLUMBING [J MECHANICAL [J GAS P(ROOFING TYPE OF CONSTRUCTION: [J BLOCK $ VALUATION OF TOTAL CONSTRUCTION AMP SERVICE D FLORIDA POWER D W.R.E.C. $ VALUA'l'ION OF MECHANCIAL INSTALLATION [J SPECIALTY [J OTHER D FRAME D S'fEEL D OTHER FINISHED FLOOR ELEVATIONS IS PROJECT IN FLOOD ZONE AREAD YES [J NO BUILDER COMPANY STATE CERT .OR REGIST ff CITY PROCESSING 1# SIGNATURE ****************************************************************** 'COMPANY STATE CERT OR REGIST II. CITY PROCESSING 1# ELECTRICIAN SIGNATURE ****************************************************************** PLUMBER COMPANY STATE CERT OR REGIST 1# CITY PROCESSING II SIGNATURE * ** ****** **.** * ******* ****.**** * *** * * * *** **** ***** * ******* ****** *** MECHANICAL COMPANY STATE CERT OR REGIST It CITY PROCESSING 1# SIGNATURE ., ******************.**.*...........*.***.***..*.*.*~************** OTHER 7J/hJt COMPANY MILBAR ca.ISTRUcrION, INC. STATE CERT OR REGIST 1# CCC 051562 CITY PROCESSING It 218 SIGNATURE ***************************************************************** CONlJl'l'lONS 01:' l:'I:;HMl'!' Al:'I:'llJAV1'l' A. NOTICE OF DEED RESTRICTIONS The undersigned understands that ';this permit nlClY be subject to "deed restrictions" which may be more restrictive ,than City regulations. The undersigned assumes responsibility for complian~e with any applicable deed restrictions. B. UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES If the owner has hired a contractor or contractors to undertake work, they may be requir~d to be licensed in accordance with state and local regulations. If the contractor is not licensed as required by law, 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, 613-766-6611. Furthermore, if the owner has hired a contractor or contractors, he is advised to have,the contractor(s) sign portions oftpe "Contractor Sections" 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 ~icensed and is not entitled to permitting privileges in the City of Zephyrhills.. C. TRANSPORTATION IMPACT FEES AND UTILITY CONNECTION FEES D. CONSTRUC~IO~ LIEN LAW (CHAPT~R'713, FLORIDA STATUTES, AS AMENDED) I certify that I, the applicant" have been provid~d 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 promise in good faith to deliver it to the "owner" prior to commencement. 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 regul~ting 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 IRay apply to the intended work, and that it is my responsibility to identify what actions I must take to be in compliance. Such agencie~ 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 ~ealth Uni~-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 "A" or "A, etc.", it is understood that a drainage plan ~ddressing a "compensating volume" will be submitted,which is prepared by a professional engineer registered in the State of Florida prior to permit . issuance.' .. A permit issued shall be constru~~ 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 permit prevent the Building Official from thereafter requiring a- correction of errors in plans, construction, or violations 'of ~nycode. Every per~t 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 fora period of six months after the lltime the work is commenced. 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' ~O YOUR PROPER1\Y. IF YOU INTEND TO OBTAIN FINANCING,.,CONSULT, WITH YOUR LENDER OR AN ATTORNEY.BEFORE RECORDING YOUR NOTICE 0 OMMENCEMENT. JOBS UNDER $2,500 IN~VALU 0 OT NEED TO RECORD AMP POST A "NOTI ~F MM CEMENT". ! DAVID R. ABLA '.','. SIGN.Z\.TURE: OWNER OR AGENT DAVID R. ABLA STATE OF FLORIDA COUNTY OF The foregoing instrument was Before me this _ day of by DAVID R. ~RT 04 (name of person acknowledged) ~who is personally known to me, or .- acknowledged , ,1L STATE OF FLORIDA COUNTY OF The toregoinginstrument was acknowledged Before me this ---.-day of '. l~~, by DAVID R~ (name of person acknowledged) ~ho is personally known to me, or PASCD PASCD . o who has produced (type of ideritificati~n) and Who~d ~did not. take ~n oath. ~~ Signature of person taking acknowledgement ....~- Dwho has produced (type of identificatiqn) and who D~~ li!lIid not take an oath .~. 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I! .i'd" conilltiO';' It' "t! 1OfV'1flCl1I'~ ut~'C1, Vou .,. aLltllorlhd Il9nnn 1.1 .....,.,......,..tw ~atlVHl "" mIcM ..OU'.neCl."'~.~~~. '~~, D8t1tolAaOlCMlW' /~ ..., I~""'LJI/ SIp1In---- .- y . .: ,_ _., . "._ ....r.. I '. ..,n. ,'. .,;...... ...- - . .. -:(. _I, w ..' /, ,,> NOTICE OI? COMMENCEMENT MeI # l:t:J.!i:; Permit No. ~ Parcel I.D/FOLIO # 1\ ,- ~ CD - on - bl,)\ L") ~- \~ Sb(J ~()\ \ D State of Plorida COWlty of ;PD-..~ THE UNDERSIGNED I~ereby,fgive' notice that the::lmprovement will be made to certain real property "in~ a~~ord~hce with Chapter 713. ~1orida Statues, the following information is provided in this notice of commencemcnt. ':' , ' 1111111111111111111111111111111111111111111111I111I111111111 2004202267 Rcpl: 826970 Rec: 10.00 os: 0.00 IT: 0.00 10/29/04________ Dpt.y Clerk ..-' .. ~ .. . JEO PITTMAN~ PASCO COUNTY CLERK 10/29/04 00: 38am 1 of 1 OR BK 6087 PG 122 . ' I' 3.0wner information a)Name and addrcss b) Interest in property c)Name and addres of ~ e sian 1 - ;L 1/ 4.Contractor (name and address) 15911 U.S. 301, DADE CliY, FL 33523 5.Surety a)Name and address b)Amount of bond 5.Lendcr (name and address) 'i ~;. .. j.... " 'o'~ " . ''I" 7.Person within the. State of Florida designated. by owner" upon who notices or other documents may be served as ~rovided by Section 713.13( 1 )(a)(7), Florida Statues. ' Name and address Un addition t~ hinf or 'herself, owner de~ignates )f to receive a copy of the Lienor's Notice as provided in Section. 713.l3(l)(b), Florida Statues. 1.Expiration date of notice of conuncncement rom the datc of recording unlcss a diffcrent date is specified). .- (the expiration date is one year ,11 ... )T A TE OF FLORIDA CMNER 's SIGNA'lURE COUNTY OF~'i6Q JC) P!UNTED NAME & 'rr'l'LE " fhe f~llowing instrument was ackJ1owl~dged before me this~ay of who is personalll: known ~ho~rodUCCd I\fter recording, return to: ';. .', . .' <, ~ame MILBAR C0I'~STRUCTION. INC. R' . A.ddress 15911 U.S: 301 :ity Dade City, FL33523 Name(print) Title or rank Serial number, if any O:wv\rwr:S,:tt:o,u#. 'b'b OO~D YD'f