HomeMy WebLinkAbout05-5193
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
5193
Permit Number: 5193
Permit Type: ADDITION/ALTERATION
Class of Work: 434-ADD/AL T RESIDENTIAL
Proposed Use: SINGLE FAMILY RESIDENTIAL
Square Feet:
Est. Value:
Improv. Cost:
Date Issued:
Total Fees:
Amount Paid:
Date Paid:
Work Desc:
Address: 38323 13TH AVE
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot{s): Block: Section:
Subdivision: CITY OF ZEPHYRHILLS
Parcel Number:
9,600.00
11/29/2005
155.00
155.00
11/29/2005
SUN ROOM
Name: ALFRED & LORRAINE SCHLEUSNER
Address: 38323 13TH AVE
ZEPHYRHILLS, FL. 33542
Phone:
N
GEORGE TEANO
~ 1
Iv,n/
~\1 0 _ jf ~l v '
0-t~
D J
r0
l~
TER
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,
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
CITY OF ZEPHYRHILLS PERMIT APPLICATION
BUILDING DEPARTMENT 5335 8TH St, Zephyrhills, FL 33542
813-780-0020 FAX: 813-780-0021 11-/7- tiS'
J f DATE RECE IVED -
o u /JJn fV4Ab/ ,/
PHONE CONTACT FOR PERMITTING 7017 - .) 0 If' 3/ 8 ~
OWNER'S NAME
I/Aeb
3[) 5~ ~
<5ih /~ /LI ~ /V ~ /L-
/3f!cJe- ~
PHONE
JOB ADDRESS
LEGAL DESCRIPTION: LOT(S)
BLOCK
SUBDIVISION
PARCEL ID #
(OBTAIN FROM PROPERTY TAX NOTICEl
WORK PROPSED: [JNEW CONSTRUCTION
[JADDITION
[JALTERATION
[J REPAIR
[J INSTALL
[J SIGN
PROPOSED USE: [JSGL FAMILY DWELLING
[J COMMERCIAL
[JMOVE
[J DEMOLISH
[JMULTI-FAMILY
[J INDUSTRIAL
[J # OF UNITS
o SWIMMING POOL
[J MOBILE HOME
o OTHER
DESCRIPTION OF WORK
c=J RESTAU~ HEALTH DEPARTMENT APPROVAL
SuAJ ~OM
BUILDING SIZE
~;< ~ f
SQUARE FOOTAGE
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.
IF SIGN PERMIT ONLY (2) SETS OF ENGINEERED PLANS REQUIRED.
PROPERTY SURVEY REQUIRED FOR ALL NEW CONSTRUCTION.
PERMITS REQUESTED
[J BUILDING
$
1, too,:) tf
AMP SERVICE
VALUATION OF TOTAL CONSTRUCTION
[J ELECTRICAL
o Progress Energy [J
W.R.E.C.
[J PLUMBING
o MECHANICAL
$
VALUATION OF
MECHANCIAL INSTALLATION ~ ~ (1)
o GAS
o ROOFING
o SPECIALTY
o OTHER
TYPE OF CONSTRUCTION: 0 BLOCK
[J FRAME
o STEEL
o OTHER
IS PROJECT IN FLOOD ZONE AREA[J YES [J NO
FINISHED FLOOR ELEVATIONS
COMPANY
STATE CERT OR REGIST #
******************************************************************AA~r;,
o I .'l~
~ -<so. .~.
ELECTRICIAN ,'3. COMPANY I e. A Iu 0 2/ e. c IL I C ~
SIGNATURE ~~ :;"4._-,,/--/ STATE CERT OR REGIST i b~ \:1=;).-5 ::ILl
*******************************************************'k**********
PLUMBER
COMPANY
SIGNATURE
STATE CERT OR REGIST #
******************************************************************
MECHANICAL
COMPANY
SIGNATURE
STATE CERT OR REGIST #
*****************************************************************
OTHER
COMPANY
SIGNATURE
STATE CERT OR REGIST #
A. NOTICE OF DEED RESTRICTIONS
The undersigned understands that this permit may be subject to "deed restric~ionsHwhich
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 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(s) sign po~tions of the "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 indica~ion 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 promise in good faith to deliver
it to the "owner" prior to corrunencement.
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 corrunenced 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 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 "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 corrunenced 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 corrunenced. 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 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".
SIGNATURE: OWNER OR AGENT
SIGNATURE: CONTRACTOR
acknowledged
,20_
STATE OF FLORIDA
COUNTY OF
The foregoing instrument was
Before me this _____day of
by
STATE OF FLORIDA
COUNTY OF
The foregoing instrument was
Before me this _____ day of
by
acknowledged
, 20
(name of person acknowledged)
Owho is personally known to me, or
(name of person acknowledged)
[1ho is personally known to me, or
o who has produced
(type
and whoO did 0 did not
of identification)
take an oath.
o who has produced
(type of identification)
and who Odid Oiid not take an oath
Signature of person taking acknowledgement
Signature of person taking acknowledgment
Name typed, printed or stamped
Name typed, printed or stamped
SKETCH OF SURVE r
'fYPe OF Wl?VEY: goJj1JfJARY
40 (I 20 4C)
~~ I-I
GBAJIalO 8CAU1 (lD rnt.)
1 luc.b - olD n.
NOTE:
BEARINGS SHOWN ARc BASED UPON
RECORD PUT OR OeEO OESCRIPTlON
...
~
~
b
""
.11
I.or
13
BLOCK 24 . ....
\.0.08
'1~~1tj' tJ.
....
. 140:00' p. AsPH"LNLJE ..--
~
Logal Oe8&riptlon
Lots 11 4r 12. 8/ock 24. CITY OF ZfPHYRHILLS.
according to the PIClt thtJfeof, as rocorded In Plat
Book " Page 54. of the Public Rr:cords of Pa:n:o
Coun ty, FlorIda.
CommUf'llty Numbtr. 1202.J5 Panel: OOOS
Suffl1c: X F.I.R./J- Date: 12/77/'997 Flood Zone: X
Field Itbrk: 7/25/2005 Completed: 7/26/2005
~
:I:. l>- \
~~~.\
~ '))~
~m~
~
--
GENERAl. NOTES:
'1 LEGAl. OESCRII'TICN PRO'. 'IND BY 07UEl/S,
.., 1IIE /ANDfi $//OWN HfRiQN IffiIE /lOT MSTR(llJ1Ci) ,I'CR EAlalEIlT$
011 01lEl? IlECORDED Bl:llUlJ1WJCES NOT SHOWN ON THE MIlT.
J) llNDE1IOIfClUJD !,Q/ff/Clt/$ "" FOOTN:;S, FOIhIDATIOIiS OR OT/1tf(
/lIfPF/f)VfUEM'S MRE NOr tCCl TEf)
() Wo4tL 7If3 tIRt ~ THE FAtE Cf 'Mi ItlW. AiID
ARfNOTTOIIE lJSEll 1OR6CON!JTfW(;TtJ/Xf/tJAIffU/tIES-
Si OM. Y VJSIlLt EIICffOACHUEtfIS WCAliD,
6) ~ ~ TI(lN FtJlN) ON PRrJ/18/TY CORNE(I$I.JMf$$ 07HERW/SE .wlI4lll,
l) IJIMfNS/ONS $HCt!1N1fM P/.AT AilflIIEASJJRED /lM.ESS o1'HtRWrSE $JfClNfI,
6) FEM:It~#)TDf7ERIIINED.
J) ELEVATllIoS IF SIONN ARE iAUO I.J/'CN .4lG,I(D, IINLESS 07HElWofS/t /KITED,
10) BEM/NO$ flE'ElIlIQD 10 LJN€ NOTED B.R.
II) 1){lS SlJRVEYDEn:TEDHlRE FOftM$ A Cf,O$ftJ GEa4f71IIC FlGlJliE,
12) If) IAlflERORWND IMP80VElJENTJOR VlSIlILEjt,$TALJ.Al'lOt.$
HAlF BfENLOCA'fE(JOT/fER TIWJ SfClWI'
131 AU 11IRJif()ANIJ,UONCiJf/I/i;S/lRESHOWN ro Tt€CHORDDISTANCE
14) THJ$ stAIlIliY IS fIRUAfW} fOR THE EXOWSM; IJ$E AND BENEFIT OF' N
IWITI9J4I$TtDHERfOII/. UABJL(TY1o THlRDPNl11ESUAyIl/OY'E
11lANSFtRfttD OR /l$$IOIe,
IS} NOTlCr THIS tlRA~UAY~T Bf 10 SCALE DUE ~o EI.EC'TRONIC ~MSl'D
1Ii) NOTa' rHIS 0fIAw./G PREf'AllifJ IN CIJI.fJR, $tJRVEY 'KJ/D IF NOT IN COJSJII.
11) tHIS 6l.IRiIfY DOi$ /IIOT REf/.ECTOR 0Emf11l/JlfC Or/lNER$Hlf>,
II) FfIt/CE CORNE/?S AM} 8IJR.DIm CCf/NAS ARE 'M7NESS WN/J/JENTS
10 Qg$~TiD t:CII~, DIJEJOSK)/I/S ARf;4.49 9HO'MI.
19) SlJ&JECT TO ANY IJE~TIOtJ. .lItITAT.r:W$, Il~TRICTKJNS. REseRVATIOIIS.1INl)I
Oit WQIfNTS OF RfCORD. /to E:WWl TION ()f rmE ltIADE sySlllM'lDl\',
20) T/oIIS SlJRI'fV1S v~It1INI!CCORIJA1JCEIN/THf,S. W1M2. fORA i'CRlCDOI'
IIIl DA'" FIIOM nil DATi 0;: CEImFt:A TION.
THIS SLlIlWY IS ND'r ANAL T.4l4C$41 (.Af.IO nTI1i'S/JRVEY
THIS SUIl1.fl'm WTillDfOfOfl WOII~Ctt RMIWoClPlJRPOSfS GWLy. f~'G"'l5111S r
FOR TIfIS LISE BY _ 10 1lfIQI/" 16 CEIl~lI. TI/I$ $UlWY IS NOT TO BE L6ED FIJIl
co...snut;rx;w 1'fRMIT7N4 D/;$13N0Ii tU/YOl11l>R USE W1TH01/T THE WIlfTTENct1N$$NT
Oi f/R$l..~ 811R\fl'CIR,\\ INC.
F r, t
r- n;l 11 l' i ;1 I
~ 1I I. \ l' \ U .. " ,
I 11 L' .
CENTRAL FLORIOA
950S. WlNTCRPARKORIVE
SUJrE230
CASSE~8ERRY, F1. 32707
~,' (321)3fJ1~1
fBY. (321)39;-222:1
~
. . .' :I~ , : ~,.-: i..
;,.J ; ....,'
x,
Ill-
f/r l.Il.
~
\'0)
UI
'0.
------
--
CfIrliRfIfi To;
LORRAINE SCHl.EJJSN~R; CAGlE "TLC fiRST A"~RlCAN
77n.E INSURANCE CO/JPANY; SEA me MORTGAGE, its
dUCCMtIOf'S and/or O3tlignl3.
Proplli1y Addreu:
J8J23 13TH A VENUE
ZEPHYRHn..LS. Florida J.J542
Survey Mlmber. 0-151J17
NOTE'
III ~Ii wmt I'lc:lRllM STA 'f/JE6 6lQI'04.QUr (S) (f). IF ux;,tT/()IiOl'
ENiEJlfNTSORRKJH1-Cf-WIoYOF RECOIW. OTHfR TH4N 'f/fC$f()fi~D
PL.4T, IS REOI/IRED. TH/$INFI)IllIATIOIiM/JSY 8E FlIRJiISHEl) TO
TJ1E SilRVE'rlJR AND IMI'I'tIt
FOR RE~RENCE ONL Y
NOT VALID UM.ESS SEALED WITH EMBOSSED SEAL AND SIGNCD IN RED INK
UNLESS THE SURVEYORS ELECtRONIC SEAL IS AUTHORIZED,
PHOTOCOPYING FORBIDDEN CDPYFlIGHTCD oVA TERIAL. @)
Wif!IQ
-=-= ~,.JEarN7PioWE FO FtxHJ ~ It.(X)D afCK
_._._ WIRE~f II(ft NDNRAoIAl - C(lA!:, 9l.DCKWilLL Tl'f.
. PROPEllrfCOllNfR MI. OVEP/fEAD /JE$ CIIiiEJ ~~.e.,AREA
. BfTEB6ICHUIIIlJ( p.p, POWERPOLf ~ ..............,.
ENCR E"/C//OrACHMf/fT TJ( TRANSFORMEFI lo( F/6l,(J 1Il~
f CElMIll.K CAW CAD/.ERlStfl P. Pl.AT
c.~ CCNCReTflIDNl/UENT Wool! ~TER~ c. CALC/4.II!'!:'D
1(( iRtJItIlfOO TfJ., TEl.Ef1WJNlFACJL/Y/f8 ~ r::::;:WAY
II', IIlONPIPE //,/1, fJEAR/NfJIWIlRENCE (J. r:EN~I~TA
'df ~&.$EMENY ~ ~L Tf: t lENIJTfI
DoE. M4~GE EASEMfIfl.~~..... R fW)//JS /lWJ1AlJ
" r M: AIR CONn, --= I) /JESCRlPTJDN oR DEfO
Of,., 1J1II.I1Y(ASEIlIiNT ......""".....
f'G, PAGE 7,0,8. ,.... yr -- C CNORD
p.B. P1ATBOOK w.e. 'M'fNSS$tCRJEJI Cl! r:HOIlD 'fAR/N6
1'.0." PC/f{f0l/1,JIif; l;aw. WGOFWATER Ff. ~1M$HE()Fl,00R
P,C POMOFCIIRV/ITIJRE _ EJiISTINOfl.EVA71ON ~,~~ =~~__
P,R,C. POINT(1F~(:jJRVE :N.S. ~~E PoC,!', ~tJTCOtiI1IOI.';O,d"~.
~,=TMt3ENCY F,(>ft FCilNtJPAIlKEJN(AlONN.~4 P,t POIN1OFfNTEfl$tC'fl()ll
O,lU OFFICIAL flEO(JRfJ$ B(IOI( p, /lEFEJlENCE IIO/t/IMEJ{T 0 TRt.E Cl)RNER NOT IlECCIIfR<<I
I HEREBY CEIl IS A TRIIf ,tW CORRECT
REPRES9ITA D UNDfR /JY DMCT1QII.
CARL UlCHAEL SIIITH
WIllIAM D. TUSING
srA TE OF Fl.ORIDA
'AW~mNO, 3N
LAND SURVEYOR & UAf'PER NO. 6148
,-
NOT 1/.41.10 'tI/fTIIO/Jr .4N AmHENTr.A TED fLEcmoNiC S/I3NA TIIRE AND ~tJTHENT/CA rED atcTROIIIC S~ MIfJI:lR THlS /lAP
I$I(lT IbILi> WfTWJtJTTHESlGNATIJIlE ND TlfEORII1IN.4I. 1W$lQ.stAl OF A fl.tRll1IIlCENSlQ ~ AND~,
-
---
CITY OF ZEPIIYRHILLS BUILDING DEPARTHENT
17/ F/l; e-LJ' S~h Ie AJ.< AJ e ^-
3g3~..3 /34ue. 2~fltA-j,lls
L.. of- // ~ /~ 81oc-k 02 d
PARCEL I.D.' # F
OWNER
JOB LOCATION
33 sLj~
SHON ALL EXISTING & PROPOSED STRUCTURES GIVING DIMENSIONS & SETBACKS.
UTILITY BUILDING
MUST SHOW SIZE &
FOUNDATION INFOR,
MATION. ' I
A.Ll WORK SHALLCOMPL VWlTIIALL
r'REV AlLING CODES, FLORlDASun.DING
CODE. NATIONAL El.E:TRlCCODEAND
cm'0FZEPHY""" JF:DINANCES
1/ /']Jf~ r
OM
~
II
ILlj' '2b'
I_IL-
<6' .
A ...o--.l~-\ ~
'~~ fWf\
FRONT
$ l"-\ 4J \ ~
Fo-lMdy
HoLA.s e
STREET
v~
(NOTE EXAMPLES 1 & 2)
1. SETBACKS FOR Rl, R2 ZONING
60'
10'
P E
R X
0 ,I
10' P S 10'
0. T 1 0'
S I
E N
D G
20'
FRONT PROPERTY LINE
2. SETBACKS FOR R3 ZONING
60'
10'
10' EXISTING 10'
1 0
PROPOSED
20'SGL FAM 30'DUPLEX
FRONT PROPERTY LINE
FLA, 1977 lAWS
~s 713.1:.1'
SEMINOLE FORM 408
NOTICE OF COMMENCEMENT
~=~::;f o~lo';da } ".:.... 'N .u..'c._. ~~~~~1!~1I1111111111111111111111111111111111111
The undersigned hereby informs all ~oncerned that improvements will be made to certain real property. and in accordance
with section 713.13 of the Florida Statutes, the following information is stated in this NOTiCe OF COMMENCEMENT.
Description of property".,' ?:P. :f... .11..-:-: ./~...,.... 73hd", .~. f,..",." ~~/,17. ,~.I: Zpl;:lt.LIIs
. . . . . . . . . . . . . . ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rcpl:943539
DS: 0.00
11/17/05
Rec: 10.00
IT: 0.00
Dpty Clerk
. . . . . . . . . . . I . . . . . . . . . . . . . . " . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . . . . - - . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General description of improvements ...... $~ j.,), ~. . .5ot!? ~ .~.. 00 . , . .. , oof. ,/.J. I.. .. .. . , . .. .. , . . , .. .. . , , .. . , .' , ..
Owner.,. ,4.1. f./l.-:,~.b.., ..,$c;-;h.lt:..-v.s,tv..e. ,~...........,......," ,."".,.""""...,...".,."..".,....,
Address. ,3.<&,,$. ,,;?-, ,$. ,. .......I~.Al/. ,~...... .., .7.~h''I.~h/.I!.s,.",.. .~$.s.t/~, ,.....,...'" ...
Owner's interest in site of the improvement. . . . . . . . . . . . . . . . . . , . . . . . , ., , :. . . . , , . . , . , , . . , . . , . , , , , . . . . , , , . , ' . . . , . , . , . , . . . . . , , . . ' , . .
Fee Simple Title holder (if ether than owner)
Name ",.',.. ,.',.,.."..', ,..,.....,...............,.....,.....,',........."...
JED PITTMAN. PASCO COUNTY CLERK
11/17/05 12:24pm 1 of 1
OR BK 6700 PG 1326
Address "...".".."""".."',.............,..........,...".......".".",.,.".".",..",.,.",....""""",...,,.,.,.,
~ ' , . '
R Cont,acto'. ./J.."Ic..&.... (!.P.+!.$.I",.e.",hi)h..J -<<-'F..r......................................... c. .....................
Address.,... ,.9,y>o.". ...::s;,~.'.-:c(.4k:.../5/~,...... ..EI, ,.' ,., ~,.$. ,?,?~...., ,. ,'. ...,....,..' ",'
Surety (if any) ,......".....,.,.'",.,.,..",.,..,...,.",..,......,..,.,..."...",..,..,',.,',.,.,.,",..,',.,.,.,"""",...,'
Address .....,..."..".....",.......,..."...,....,....,........"...."...:".."."".",. Amount of bond $ , , . , . . . , . ' , , , . .
Any person making a loan for the construction of the improvements:
Name ".' ..",..,...',."...",..,...,..,......,..,.... ......,......,...."...,.",.. ,..',.'" ,..'"..'.'",.,.'.',.".", ,...',
Address .,.,.""...,..".,..",...,.....,.,..,.........,......:..".,.""""",.,.""",.",.,.:",.""....""".".",",.
Person within the State of Florida designated by owner upon whom notices or other documents may be served:
Name"." ,...,.'" "",'.', ..,..., .,...' ......,....,..,...,. ..,.".',..." ...",.."",.""..,.."..,.,. '.'.,.'"""""", '.
Address .",."".",.".....,.".,.,....,.".."....,...,...,....,.......,....."",',',..,"',.,.,',..".".,.,......,......,'
In addition to himself. owner designates the following person to receive a copy of the lienor's Notice as provided in Sectior:L.,,"
713.13 (1) (hI. Florida Statutes. (Fill in at Owner's option). (/
, Name
." ,~I'~~ __, ,~~~~~~~, ,...":.....,,. ..' ,."...,... .,.""""",.,."".."""..."".,"""," ",' ,"
Address". ,;\~,~,~,.~, ,.', ..I,~~, "...~~~,.,..,"',. ,~p6''fI':",4//~:.""",? ..~~9,~, ""',','" '.., ,."",
, THIS SPACE FOR RECOR~ER'S USE o II! LY ,'" - , ~ ;;I "
,~/<..,,*~t:.~&~,, .'""", ".""
Owner
6T ATE OF FLORIDA
COUNTY OF PASCO
THIS IS TO CERTIFY THAT THE FOREGOING IS A
TRUE AND CORRECT COpy OF THE DOCUMENT ON FILE
OR Of ~8L1C RECORD IN THIS OFFICE, WITNESS MY
HAND AND OFFICIAL SEAL THI'S~ DAY OF
A IOU 2~ '
JED PJZ~AN~R"K 01JRCUIT COURT
BY IlL/. HIO '[J./ DEPUTY CLERK
Sworn to and subscribed before me this", ~"!~:."""""""
....I?.1!...,..,..day of "'," ,k~k~~"h:---:"""."".""""" tk.SL~:~'!?"