HomeMy WebLinkAbout04-3539
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
3539
3539
Permit Type: ADDITION/ALTERATION
Class of Work: 434-ADD/AL T RESIDENTIAL
Proposed Use: RV PARK
Square Feet:
Est. Value:
Improv. Cost:
Date Issued:
Total Fees:
Amount Paid:
Date Paid:
Work Desc:
Address: 3534 MALACHITE DR
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot(s): Block: Section:
Subdivision: EMERALD POINTE RV RESORT
Parcel Number:
24,744.00
11/01/2004
358.00
358.00
11/01/2004 Phone:
ROOM ADDITION,SCREEN ROOM AND SHED
Name: JACK & BETTY SHEA
Address: 3534 MALACHITE DR
ZEPHYRHILLS, FL. 33542
CRANDALL, RICHARD
CHRIS BAHR PLUMBING
BAHR'S PROPANE GAS & AlC, INC.
PLUMBING FEE
EL
45,50 MECHANICAL FEE
35,00
F
DUCTS INSTALLED PRE-SLAB CONSTRUCTION POLE 2ND ROUGH PLUMB
DUCTS INSULATED LINTEL PRE-METER WATER
SHEATHING FRAME MISC SEWER
MISC INSULATION WALL MISC MISC.
MISC. INSULATION CEILING MISC. MISC,
MISC, DRIVEWAY MISC, MISC.
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: 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.
~rl~# ~~
CONTRACTO IGNATURE PERMIT OFFI
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
CITY OF ZEPHYRHILLS PERMIT APPLICATION
BUILD:ING DBPAR'l'MBN'r 5335 8'l'11 st, Zephyrhills, FL 33542
813-780-0020 FAX: 813-780-0021
DAD RECEIVED /0 - ;) b - 0 V
PASCO Pf;RMlT SER.\fJ(
PHONE CON'l'AC'r FOR PERMIftING [-~(cCc-'i5;a.tf-7g9lf
OWNER'S N1\ME 7TfLCK {' &.II~ Jt!A.It ..sA~ (i...
.3Sdl! 1J74../a..el/ k IJrire
LEGAL DESCRIPTION: LOT (S) / eJ,7 BLOCK
PARCEL ID # eJ. 'I-~/' -01-1- OOl/-d- oatt)- /61-7 ()
PHONE
JOB ADDRESS
SUBDIVISION Cl'Un/l I1J/AA
/Lv iliUJrf Phtl\l..L TWO
(OBTAIN FROM PROPERTY TAX NOTICEl
WORK PROPSED: oNEW CONSTRUCTION P' ADDITION oALTERATION 0 REPAIR
o SIGN 0 MOVE 0 DEMOLISH
PROPOSED USE: IIfSGL FAMILY DWELLING oMill.TI-FAMILY 0# OF UNITS
o COMMERCIAL o INDUSTRIAL oSWIMKING POOL
o INSTALL
o MOBILE HOME
o OTHER
~~rI""~ lIORK room
6e.~o f~~ I I
BU LDING SIZE ,.',a Jf .a~
rlX tt.tJJ. ~'l&" \SktI tJJaP
RESIDENTIAL: ATTACH (2) PLOT PLANS & (2) SETS OF BUILDING PLANS & (1) SET ENERGY
COMMERCIAL: ATTACH (3) SETS OF BUILDING PLANS & (1) SET ENERGY FORMS.
IF SIGN PERMIT ONLY (2) SETS OF ENGINEERED PLANS REQUIRED. {7 ., I
PROPERTY SURVEY REQUIRED FOR ALL NEW CONSTRUCTION. 1JllI t,
JllliL.
PERMITS REQUESTED fJ~b.
VALUATION OF TOTAL CONSTRUCTtti~1 ~
CJ RESTAURANT & HEALTH DEPARTMENT APPROVAL
ILtItIc...".J/dA <Sc ~A rod/}... I- u kcl
,.
SQUARE FOOTAGE ~aol p
HEIGHT
FORMS .
1$ BUILDING
~ ELECTRICAL
$
~'/, 71'/. (jJ
7'7'-, <;. ~
4- ,:>-, ~ ..;.
yJ- s~
-, ').
_ ~-J
7\ .
AMP SERVICE
o FLORIDA POWER
o
W.R.E.C.
IjJ PLUMBING
ad MECHANICAL $
o GAS 0 ROOFING 0 SPECIALTY
VALUATION OF MECHANCIAL INSTALLATION ~ ,) S.3 '"1
o OTHER
TYPE OF CONSTRUCTION: 0 BLOCK
~ FRAME
o STEEL
Dl OTHER a..lum'~u.~
FINISHED FLOOR ELEVATIONS
IS PROJECT IN FLOOD ZONE AREAo YES 0 NO
BUILDER
.- -'," ," - -,. . . - . -,'~ -.. -. ... . .. ".
~moR;~~;S.CT:i:()N
.L~'~ '.'.: .-;;' . ,;,',"_,''::-':,..-:::'.'''-';,-..:.r.;,::. ...,;;,.;..:.~".;;:!.-, c,. :-,C;,._ ';:'.~.,:,. .:'::,..:_:
COMPANY cS UIl tS.Ju A~. -XAC .
SIGNATURE ~I-CL e~ ~I L
STATE CERT OR REGIST #
******************************************************************
ELEC'rRICIAN i .
SIGNATURE ~4~ Cz~
COMPANY
C rfllLtI a.J /
c k't.Jrie-
STATE CERT OR REGIST #
******************************************************************
PLUMBER 7 COMPANY cbi! 13J.r jJk.A./;/~9
MECHANICAL COMPANY /3oJtr'5 Pr()pan~ G~ ct- .4-/~
SIGNATURE STATE CERT OR REGIST # c~ c..o ~~9" y~
*****************************************************************
OTHER
COMPANY
SIGNATURE
STATE CERT OR REGIST #
A. NOTIGE OF DEED RESTRICTIONS
The undersigned understands that this permit may be subject to "deed restrictions" ~hich
may be more restrictive than City regulations. The undersigned assumes re~pon5ibility 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 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, 813-780-0020.
Furthermore, if the owner has hired a contractor or contractors, he is advised to have the
contractor (5) sign po~tions of the "Contractor Sections" of this application for which the
will be responsible. If you, as the owner signs as the contractor, you are indicating tha
you, rath~r than the contractor, are responsible for the work. If the contractor wishes
you to sign as contractor that may be an indica~ion that he is not properly licensed and i
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 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 regulating construction, zoning, and land
development.
Appli~ation 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 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 other governmental agencies may apply to
the intended work, and that it is my responsibility to identify what actions I must take t(
be in compliance. Such agencies include but are not limited to: *Oepartment 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 "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 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 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 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'c
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 si~
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, CONSUL1
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. JOBS UNDER
$2,500 IN VALUE DO NOT NEED TO RECORD AND POST A "NOTICE OF COMMENCEMENT".
SIGNATU~~ o~!!-
~~ea k/L
SIGNATURE: CONTRACTCR
STATE OF FLORIDA ...0
COUNTY OF r tt $Co
The foregoing instrument was aCknOWledg~d4
~;fO~~ci-;~~..~;:- day of C)r~bt r , 2 IJ
(name of person acknowledged)
Etwho is personally known to me, or
STATE OF FLORIDA
COUNTY OF
The foregoing instrument wa~ ~knowledged
Before me th~s q~?!:;"ay of Urt'l>bu , 200!L
by ~fl.l.i n
(name of person acknowledged)
~ho is personally known to me, or
Pasco
o who has produced
(type
did''':~id not
o who has produced
(type of identification)
~id not ta e an oath
of person taking acknowledgement
""Ii,, Suzanne Bahr
,'~~~Y.~lJe:// .. I ~ ~ 3 '
'::"'mrl~- CUIIII"I~wH1l1D;D 5 I
Name typed, p~~~._~:;~!xJ5'lr'e~q5, 2006
-;.;?~.. ' 'c/'/ Bonded Thru
"1111~~t\\\\\ Atlantic Bor:ding Co., Ine
Signature 0 rson taking acknowledgment
"""" Suzarme Balu
,,~tl'V PUll", , , #DD I 5713 I
Name tYPe~(~~;;i='~~6
--;''''/~~QF f~O~~"''' Bonded .Thru
",,,,,,, Atlantic Bondll1g Co" In<:
FLORIDA ENERGY EFFICIENCY CODE FOR BUILDING CONSTRUCTION
FORM' 600c-01 Residential Umited Applications Prescriptive Method C CENmAL 4 5 6
Small Acldltlonl, Renovations " Building Systems
~ wllMehJd C Ii 0\apler61i" Fbila Energy EIIc:ierq QJde may bedenuMaled brllll use 0/ Fum8llJC.Ollor adliIOIs Ii ImSQae Ieel cr less. sile- mded ~ Ii IllllIUacUed hlmes. and
III1OIflIlions to' lIIII residen:es. Allematiwlmellods lIIe . lor ldIions use Ii FumlmHl1 cr liOOMlI.
PROJECT NAME: BUILDER: -..
AND ADDRESS: PERMITTING D D D
OffICE: ZONE: 4 5 6
OWNER: ~ 6h ()., PERMlTNO.ITIITIJ.JJ JURISDICTION NO.: CIIIIIJ
SMAlL AIJOITIONS TO EXISTING RESIDENCES 11m ScpIre!eel crless Ii aniliooed area). ~ reqliIemenls in Tables 6C-l, 6C-2 am 6C-3 applycnyto Ihe aJI1lOIll!IlIS oIlhe addilion, Id 10 Ihe existing bIiIding.
SpiDl heating, coding. and waler IleaIB,j ~ elli:ien:ylevels III1S1 be melcnyv.tlen ~ is iIslaIed speciIicaIy 10 seM! 1he addIion cr is being ilsIaIed incorjlJdon wiIIlheaddlion l:lll15N:liln. ~
separating trollIdiliooed spaces IrcmlllXdlioned spaces IIIISlmeel1he presailed ninirun insdaIim IewII&. RENOVATIONS (ResilenIaI1lIikliY.JS In1ergoing IlIIIMIilrls coslir4Il1Qlllllll :Il%oIlleassessel1 vakJeollhe
bliklDdI- ~ requitemenIs in Ta!*ls 6C-llPl6C-2 wy cny III Illl~ and ecppment being renovaled cr repIlml. IUHJfAC1lJREl) IQES AND IllJl.Dt<<>S. ~ siIe-i1slaIed aJI1lOIll!IlIS am fealIies
lIIemveredbr lis fonn.llUIlIlNJ svsrEMS~when~newsysllllllisilslaled. PI.ase Print CK
1. Renovation, Addition, New System or Manufactured Home
2. Single family detached or Multifamily attached
3. If Multifamily-No. of units covered by this submission
4. Conditioned floor area (sq. ft.)
5. Predominant eave overhang (ft;)
6. Glass area and type:
a. Clear glass
b. Tint, film or solar screen
7. Percentage of glass to floor area
8. Floor type and insulation:
a, Slab-on-grade (R-value)
b. Wood. raised (R-value)
c. Wood, common (R-value)
d. Concrete. raised (R-value)
e. Concrete. common (R-value)
9. Wall type and insulation:
a. Exterior:
1. Masonry (Insulation R-value)
2. Wood frame (Insulation R-value)
b. Adjacent:
1. Masonry (Insulation R-value)
2. Wood frame (Insuhition R-value)
c. Marriage Walls of Multiple Units. (Yes/No)
10. Ceiling type and insulation:
a. Under attic (Insulation R-value)
b. Single assembly (Insulation R-value)
11. Cooling system.
. (Types: central, room unit, package terminal A.C,. gas, existing, none)
12. Heating system.: (Types: heal pump, alee. strip, natural gas, LP. gas,
gas h.p" room or PTAC, existing, none)
13. Air Distribution System.:
a. Backflow damper or single package systems. (YesINo)
b. Ducts on marriage walls adequately sealed. (Yes/No)
14. Hot water system:
(Types: alee., natural gas, other, existing, none)
· Pertains to manufactured homes with site installed components.
I hereby certify that lans and specifications covered by the calculation are in
compliance with !he . Energy Code. i3. '
PREPARED BY: ~ ~ DATE; M I-.,It!'/
I hereby certify al this ~ng is in compliance wilh the Florida Energy ~
OWNER AGENT: DATE.
FLORIDA BUILDING CODE - BUILDING
1. ~~
2. Si~\~
3. -4
4. ~ f"J'3 i/1
5. I'
Single Pane Double Pane
6a. :3~ t/J sq. ft. sq. ft.
6b. sq. ft. sq. ft.
7. ./3 %
8a. R= lin. ft.
8b. R= II ;113 sq. ft.
Sc. R= sq. ft.
8d. R= sq. ft.
8e. R= sq. ft.
9a-1 R= sq. ft.
9a-2 R= 11 iJ70sq. ft.
9b-1 R= sq. ft.
9b-2 R= II ~~3~ sq. ft.
9c
10a.
10b.
R=
R= I~
sq. ft.
.:173 sq. ft.
11.
Type:
SEERlEER:
Type:
HSPF/COP/AFUE;
12.
13a.
13b.
14.
Type: e'~c..-t~
EF:
Review 01 plans: and specifica1ions covered by Ihis caIcuIa1ion incicales COIqliance
wilhlhe FIoridaEneruY.... Code. ~~. . is. ~lhisbuidngwill. be
inspected lor ~ in i1h' .5.
BUILDING OFFICI '_ _.:. _
DATE; '. 'U _.
13.203
Climate Zones 4 '5 6
TABLE 6C-l : PRESCRIPTIVE flEQUIREMEHTS FOR SMALL ADDIJIONS 1600 Sq. flllllll.es), RENOVAllONS TO EXISTING IULDINGS AND SlTE-lNSTALLED COMPONENTS Of MANUfACT\RED HOMES.
MINIMUM INSULATION
COMPONENT INSUlATION ' INSTAlLED
CQncrete Block R-S R-II
en Frame, 2' x 4' R-11
..J
..J Frame, 2' x 6' R-19
~ Common, Frame R.11
Common, Masonry R.3
Under AlIic R-30
en Single Assembly; Enclosed
<!)
z Frame R.19 , ~-I~
:J Metal Pans R.13
W Single Assembly: Open R-10
0 Common, Frame R.11
(f) SIab-o'n-grade No Minimum
a: Raised Wood R-11 2-11
9 RaIsed Concrete R.S
u. Common, Frame R-"
I- In unconditioned space R-6 tJ-f..
g
0 In conditioned space No minimum ~
MINIMUM INSTALlED
EQUIPMENT EfFICIEHCY EFFICIENCY
Cen1raI AIC - ~ SEER = 10.0 SEER = -
~ -Single Pkg. SEER = 9.7 SEER = -
~ Room unit or PT AC EER = 8.5* EER = -
Electric Resistance ANY
<l) Heat pump. SpIil HSPF = 6.8 HSPF = -
z . Single Pkg. HSPF 6.6 HSPF
~ = = -
:I: Room unit or PTHP COP = 2.7* HSPF/ = -
~ COP
U) Gas, natural or propane AFUE = .78 AFUE = -
Fuel Oil AFUE = .78 AFUE = -
I-ffi ' Electric Resistance EF = .88 EF = -
01- Gas; Natural or L.P. EF = .54 EF =
:I:~ -
Fuel Oft EF = .54 EF =
* See Table 6-3. 6-7
REQUIR LA
s to IIoor area allowedis selected Ie and solar heat coeffIcienl Maxlmum% = Installed % = 1$
GlASS TYPE, OVERHANG, AND SOLAR HEAT GAIN COEFFICIENT REQUIRED FOR GlASS PERCENTAGE ALLOWED
UP TO 30% . UP TO 40% UP TO 50%
Single
Get certified SHGC from the manufacturer or use defaults: Single clear SHGC = .87. double clear SHGC = .78, and single tint SHGC = .75.
CH CK
vi'
V
v
Combustion
Heatln
Water Heaters
606.1
612.1
-
612.1
612.1
610,1
-
v
607.'
v
GENERAL 0lRECTJ(l0IS:
t, On Table lK:-I iIdcaIe lie R-vakJe ollie insUalion beiv,j added 10m ~ aOO tie eIli:ieR:ylewelso/ lie ecMJmenI beiv,j iIslaIed, AI R-wUls aOO eliciencies inslaIed nu;tmeel or IllII:lIfld lie nDlunVUs isted.
~aOO~neilherbeiv,jaddednor renovated may be IeIlIWl.
2. AlJlJlTKH)OtI. y, OelelIIinelhepen:enlagliolnewgfass IOCllIxiIionedbJr lIllIIillleadrilblas IoIows. TofaIlhe areas 0/ aI glass wnlows. tiIg glass doasaOO.gIass 000r plIleis. 0lUlle lie lIllII 01 allIOO-Vl!Ili:aIl1XlI
gfass lI1d add illO IletJUViDus loIa/. MIen glass iIeUsiIY,J exterior waIs is beiv,jl1llllMldor llI1l:Oedby Ile acUliJn. ill lI11DlIlIecpII 10 tie mlallIllII o/!Iis glass may be sdnled from Ihe mlalgIass area. OWe lhe~
glassllllll mIaIbyl1ec:ondlonedlkla lIllIIoIlIe ackIlkn ....11t l00lOgetllepeltllt FnIlhelllgeslgfasspl!llBQlJelJ1derwti:hyarc:abABl pen:enlagelalson TablelK:-2. ~ are~11t1le lypeolglass
(Single or DouI*t pane) lI1d I1eCMllh8ng (Ql) paiedwill a solar .. gaill108Ii:Ienl (SHGC). For a ~ gfass Iype lI1d oved1ang.lIe n1niJua$dil' heal gailcoelII:ienl~ is spded. AcUII gfass wiIdows lI1d doas
fJ8'IiousIyillheexteriorwallsoll1ehculeaOObeiv,j reinslalIedill1eaddiliondorahavelO~wiIIl1e~aOOsoIarhealgailCOllllidenl~on Table6C-2. MnewglassillleactIUIllllSlmeellhe reqIiremenI
lor 0Ile oIl1eqJliJns in I1eglass peIllllNagecaleglly JOU ildc8IBd. 1be0ll8d81g IQi)dislance is lIIIlIUIllJlllllllllllliU Inn I)8l;aol.l1egfass 10 a paR ~ lI1dur 1he0lMrlmlil edge oIl1eClWl!llllq.
3. RENOIA1QSOtI. y, ~glassneeds 10 meetl1eldtMingmcpements. Pntgfass lypeaOO$diI'heaI gaincoelll:ientmaybeused Iorgfass areasHhare1llder alleasta IlioloollMlll1q nwmse bwesl edge
mes ra 8llIenI....lIBIBIeelInn I1e IM!Ihang. Glass areas beiw.l1llIllMIIed IlaI do rameet lis alIIlria IIllSl be eiI1er siVe-pane li1led, dWJIe.pane.. or dWJIe.pane linIed.
4, BUIUJt<<3 SYSTEMS. ~ when new systemis insIaIed lor syslem inslaIed.
5, Conl**tI1e inIonnaIon I8CpISled on the qJ hili 01 pege I.
6. Read 'Minirun ~ lor SmaI AdciIiorB lI1d fleroIaions., Table 6C-3.lI1d dleck aI appli:abIe n.
7. Read. sign aOO dale Ihe "OtmerI1qlnI" cricafon SIaIemeIt on page I. '
13.204 FLORIDA BUILDING CODE - BUILDING
JACk.' c BETTY ,-rlfFIJ
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NOTICE OF COMMENCEMENT
1111111111111111111I111111111111111111111I11111111I111111111
2004204315
Rcpt : 827818 Rec: 10.00
OS: 0, 00 IT: 0. 00
11/02/04 ___________ Dpty Clerk
State of
.
J: fA> rl r! ~
County of
fJ~ue(;
THE IfflDERSIGNED hereby gives notice that improvement will be made to certain
real property, and in accordance with Chapter 713, Florida Statutes, the
following information is provided in this Notice of Commencement:
1.
Description of Property: Parcel No. .1l/-,;Jt,-~/-o()tj(}-O()()(X)-/627tJ
.35.J t/ /)J a.l ~(! J; 6... tJr . E IJJ. ra.-I/ ;;0 u...&.
(Legal description of the property and
Pj/-J t,1 /eJ7
street addre~s if available)
3.
JED PITTMAN, PASCO COUNTY CLERK
11/02/04 08: 32am 1 of 1
OR BK 6091 PG 556
Owner Information: Name ~Q...(J/( ~ &J../y 7-b'tJ.- \Sh-e.~
l~ddress ;j~ det /JIa./reki.L /Jr. City 2qJ4/'U/J
.J'CA..aA.
'\S kcl.
.
i()OP7
c
2 .
General Description of Improvement
roO/Jt
aLtlll,tJ/l
,
State fl. .l3S-lId
Interest in Property:
Name of Fee Simple Titleholder:
(If other thgn owner)
Address
City
State
R'tontractor: Name S~
Address ~/SCJ Hrl k../JJIj
cJk&. Atu.n..//J//^. .LAc
I2acd City Zef;4;rl.t.l!.r
State.FI .u5VoL
5. Surety: Name
Address
City
State
Amount of Bond: $
6. Lender: Name
Address
City
State
7. Persons within the State of Florida designated by Owner upon whom
notices or other documents may be served as provided by Section
713.13(1) (a)(7), Florida Statutes:
Name
Address
City
State
8. In addition to himself, Owner designates
of to receive a copy of the
Lienor's Notic~asprovided in Section 713.13(1)(b), Florida Statutes.
9. E:xp.l.rl1Li.on date. of Notice of Commencement (the expiration date is 1 year
fr?m the date of recording unless a different date is specified.)
i / -\ il
signatureofowner~~~~;Y ~J0~
Sworn to and subscribed before me this cXtJ~ day of ({JC.:fD6er-
· p'(f)()f.
Notary Public:
13~
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PC93053048