HomeMy WebLinkAbout07-6979
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
6979
Permit Number:
Permit Type:
Class of Work:
Proposed Use:
Square Feet:
Est. Value:
Improv. Cost:
Date Issued:
Total Fees:
Amount Paid:
Date Paid:
Work Desc:
6979
RE-ROOF
ROOF REPLACEMENT
SINGLE FAMILY RESIDENTIAL
Address: 39528 MEADOWOOD LP
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot(s): Block: Section:
Subdivision: MEADOWOOD ESTATES
Parcel Number: 13-26-21-0140-00000-1230
3,465.00
8/24/2007
50.00
50.00
8/24/2007
REROOF - SHINGLES - 30 YR
MILLIGAN, CLA N R.
39528 MEADOWOOD LP
ZEPHYRHILLS, FL. 33542
Phone: 852 715-4802
(:Y\A/1vl OJ
~q/
REINSPECTION FEES: Reinspection fees will comply with Florida Statute 553.80 (2)( c) when extra inspection
trips are necessary due to anyone of the following reasons: a) wrong address b) condemned work resulting
from faulty construction c) repairs or corrections not made when inspections 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.
NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that
may be found in the public records of this county, and there may be additional permits required from other governmental
entities such as water management, state agencies or federal agencies.
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."
TRACTOR SIG ATURE PERMIT OFFI
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
813-780-0020
City of Zephyrhills Permit Application
Building Department
Fax-813-780-0021
Date Received
8 2 f)t
In .f. (Y):(I, A..J /'
rnfl~dDWbaJ cf
Owner Phone Number
Owner Phone Number I
Owner Phone Number I
Owner's Name
Owner's Address 13 ~ 5 28
Fee Simple Titleholder Namel
JOB ADDRESS
Fee Simple Titleholder Address I
13q5~~ fYW.a..c\~~& LV')
l/JJf~w -lS-h, # J
LOT #
SUBDIVISION
PARCELlD#ll~ --2(0-2-1 - 01 ~D -o()Ooo. j230
(OBTAINED FROM PROPERTY TAX NOTICE)
I
E3
D
D
s/, ';'9 /IU
BUILDING SIZE SQ FOOTAGE 1.)(40 HEIGHT I
1IIIIlllllfT'lllflllllllllllll'III"III"11111111111111111111111111'11111111111"111111111'1'11"111111"'11111I1111111111111111111111111111111111
WORK PROPOSED
SIGN
D
MOVE
D
DEMOLISH
B
D
D
I j'2. G' - ,'2 et!
NEW CONSTR
INSTALL
SFR
BLOCK
ADD/AL T
REPAIR
COMM
FRAME
D
D
D
OTHER I Kli"-;U"! sh, ",Ie:-s.
STEEL D OTHER I
PROPOSED USE
TYPE OF CONSTRUCTION
DESCRIPTION OF WORK
1$ 3 l..f ~I: eO I
1$ I
1$ I
1$ I
D GAS ~ ROOFING D SPECIALTY D OTHER
FINISHED FLOOR ELEVATIONS I I FLOOD ZONE AREA DYES DNO
I11111111111111111111111111111111111I11111111111111111I11111111111111I11111111111111111I11111111111111111111111I111111111111111111111111111111I111
D
BUILDING
VALUATION OF TOTAL CONSTRUCTION
ELECTRICAL
AMP SERVICE
D
PROGRESS ENERGY
D
W.R.E,C,
D
D
D
PLUMBING
MECHANICAL
VALUATION OF MECHANICAL INSTALLATION
Y/N FEE CURRENT
License #
Y I N FEE CURRENT
License #
Y/N FEE CURRENT
License #
YI N FEE CURRENT
License #
Y/N
I
I
I
I
I
I
I
I
I
I
BUILDER
SIGNATURE
COMPANY
REGISTERED
Address
ELECTRICIAN I
SIGNATURE .
Address I
PLUMBER I
SIGNATURE
I
COMPANY
REGISTERED
Y/N
COMPANY
REGISTERED
Y/N
Address
MECHANICAL I
SIGNATURE
COMPANY
REGISTERED
Address
OTHER I tJi-lIJ-L() f.4~~):7/l~
SIGNATURE ~ N I FEE CURRENT r'Y)N I
Address nil- '/RA;{ ~~J~ V'C,IIlj.,:'/. 1 License # I CCCf32- C, r<1r
1II1111111I1111111111111111111111111111111111111I111111111I111111111111111111111111111111111111111111111111111111I1II11111I1111111111111111111I111
RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Permit for new construction.
Minimum ten (10) working days after submittal date, Required onsite, Construction Plans, Stormwater Plans wI Silt Fence installed.
Sanitary Facilities & 1 dumpster; Site Work Permit for subdivlsions/large projects
COMMERCIAL Attach (3) sets of Building Plans; (1) set of Energy Forms. R-O-W Permit for new construction,
Minimum ten (10) working days after submittal date, Required onsite, Construction Plans, Stormwater Plans wI Silt Fence installed.
Sanitary Facilities & 1 dumpster, Site Work Permit for all new projects, All commercial requirements must meet compliance
SIGN PERMIT Attach (2) sets of Engineered Plans,
....PROPERTY SURVEY required for all NEW construction,
Di~~~~i~~~': ' , , , , , , . . , , , , , , . . , , . . . , , . . , , , , . , , , . . , , , , , , , , , , , , , . . . . , , , , , , , . , , , , , , , , , , , , , . , . , . , , , . , , , , , , , . , , , . . , , . , , , , , , . . . , . , , , , . . , . . . , . , , . . , . . . . , , . ,
Fill out application completely.
Owner & Contractor sign back of application, notarized
If over $2500, a Notice of Commencement is required. (AlC upgrades over $5000)
Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letter from owner authorizing same
OVER THE COUNTER PERMITTING (Front of Application Only)
Reroofs Sewers Service Upgrades AlC Fences (PloUSurvey/Footage)
Y/N
Driveways-Not over Counter if on public roadways..needs ROW
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to "deed" restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any
applicable deed restrictions.
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 Pasco County Building Inspection Division-Licensing Section at 727-847-
8009. Furthermore, if the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign
portions of the "contractor Block" of this application for which they will be responsible. If you, as the owner sign as the
contractor, that may be an indication that he is not properly licensed and is not entitled to permitting privileges in Pasco
County.
TRANSPORTATION IMPACT/UTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings, change of
use in existing buildings, or expansion of existing buildings, as specified in Pasco County Ordinance number 89-07 and
90-07, as amended, The undersigned also understands, that such fees, as may be due, will be identified at the time of
permitting. It is further understood that Transportation Impact Fees and Resource Recovery Fees must be paid prior to
receiving a .certificate of occupancy" or final power release. If the project does not involve a certificate of occupancy or
final power release, the fees must be paid prior to permit issuance. Furthermore, if Pasco County Water/Sewer Impact
fees are due, they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW (Chapter 713, Florida Statutes, as amended): If valuation of work is $2,500,00 or more, I
certify that I, the applicant, have been provided with a copy of the "Florida Construction Lien Law-Homeowner's
Protection Guide" prepared by the Florida Department of Agriculture and Consumer Affairs. If the applicant is someone
other than the "owner", I certify 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.
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 meet standards of all laws regulating
construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction, I also
certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is
my responsibility to identify what actions' must take to be in compliance, Such agencies include but are not limited to:
Department of Environmental Protection-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.
US Environmental Protection Agency-Asbestos abatement.
Federal Aviation Authority-Runways.
I understand that the following restrictions apply to the use of fill:
Use of fill is not allowed in Flood Zone "V" unless expressly permitted.
If the fill material is to be used in Flood Zone "A", it is understood that a drainage plan addressing a
"compensating volume" will be submitted at time of permitting which is prepared by a professional engineer
licensed by the State of Florida,
If the fill material is to be used in Flood Zone "A" in connection with a permitted building using stem wall
construction, I certify that fill will be used only to fill the area within the stem wall.
If fill material is to be used in any area, I certify that use of such fill will not adversely affect adjacent
properties. If use of fill is found to adversely affect adjacent properties, the owner may be cited for violating
the conditions of the building permit issued under the attached permit application, for lots less than one (1)
acre which are elevated by fill, an engineered drainage plan is required.
If I am the AGENT FOR THE OWNER, I promise in good faith to inform the owner of the permitting conditions set forth in
this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical work,
plumbing, signs, wells, pools, air conditioning, gas, or other installations not specifically included in the application. 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 codes. Every permit issued shall become invalid
unless the work authorized by such permit is commenced within six months of permit issuance, or if work authorized by
the permit is suspended or abandoned for a period of six (6) months after the time the work is commenced. An extension
may be requested, in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate
justifiable cause for the extension, If work ceases for ninety (90) consecutive days, the\job is considered abandoned.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT INYOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR OTICE OF COMMENCEMENT;
FLORIDA JURAT (F.S, 1 H 3) "
CONTRACTOR
Subpcribf'!d and sworn t ~or affirmed) bef e me this
"? /.r{ I 07 by Ot...\; Y\.L. ~ . \i:::'h'" 7 I C2...-
Who is/are personally known to me or has/have produced
~ L- \)i2 ~ -2- LI. (! as identification,
~I. ~/', ~~.~
Notary Public
~''-. 0 ___
~~~~
"
Notary Public
Name of Notary ty
08-21-2007 21:01
WIZARD ROOFIN, INC 352-680-6845
PAGEl
WIZARD
ROOFING, INC.
Owner Name_:" i:. "'''1 .. J, /' ..:.2 ,!~:\Wjzrdroofing@earthljnk.net
lob Lo' ~': ... " -----. .....:------_ OateofPl'oposal_ '~... /; .. )
catJon:~-=..2~Li.._ ;': ~'.....:._,;;./-,-,J:...~_~,"-,~ _ _City .._ /'; ,; '...~~~~-
Horne Phon. i G II' '. \'. i .' '. " - - _ J....; .!......""- ~ i. ,; .' '.,
e~,);....::! I I.f ,.~.Ci~' k " ~__
~ . ---'---" ~L -4-$Wor Pholie :"'. ': ,,) '/ (', '"j ( I..
--_ , . "Ie ('. p<>v
---~- ~---
----
, 17 Fir Trail Cse
Oeala, FL 34472
(352) 266--4763
- -,-- .- -
Llcense#
CCCl326895
WE SUBMIT this estimate to:
Contract Proposal
Relllove f Jay f
- '-- ers 0 roof Clean OUI gutters and b I
au away trash caused from tear off. J ' , ,
1n.'1tall a new layer of No ;. ,', ti 1 . nstall new roof In the following manner'
"~- e t paper, nailed to deck. .
111Stall Dew drip edge: V~o C I ,,,.. .t~)
.. , ,0 or_'~",_.....:.,:,:::"" Galvanized ' .
. . - _. _ , AJullllnulll , "../
InstaJl Dew lead Pumbing flashin ,y;.~h.T - -__'
, gs, \. ~1'lO, IWltall new kitchen rang' events;
I Yes/No, Install uryc:rlbath Vent :
nstaJI new aluminum ridge-"eDt:;Ye~o Color Yes/No,
--" , - - - _. _' Feel :: :,.
Install new .~;) year Al R' , --- .'
~- gae eSlstanl FIberglass Shingles, Nailed. Color:
Seal "'~ p~, ~O >aOey" and all Ouhiug ""th roof C"","" M_d ~.~ cJC"~': - - - - - -- - - - "
,. Olher:_ --i;:...L.~'LL~'~ '\"\ I '~:x "
' ._-~"""'Cf-_~~,' l I
i"~---1 ",,' _ ':b.J:.~ ~__ '1.:... ." F-"--. ~.'.~,',,~. ~ ~..;......:.:..:t..i....i.. '~\.4-I__
-~ - ~-':~';...L:~~..J._
----
---
-.----
Product warranty for lL years.
- - ---
----
Workmanship for roof installatioll nnly Jor,r years,
WE PROPOSF, to furnish materials and labor as stated above fur the Sum of
,." '.. ...,' i I -... . -..
. !\..-",: : ,\,.'.~..'\I' 'I,-~,,,, h. ,{. I
_..~ j ......'~.....I.l~A.,...::'l.(-...'\
.....:{ l' ";
,~; t.:::...,doUars ($,.\ ~l '-cf;-, )~:
l
Upgrade shingles to 30 year architeclural, additional:$
:),
1"__
_(Owner Initilll)
----....;.._.
" Owner Initial
with p'oiyment to be due upon completion PaymeJ1t to be due in-full for all warranties 10 be valid. Wammties are not transfcnablc,
This price is for the manufacturer indicated above. Change in manufacturers may result in a price increase,
This price is good foriQ, days and is void hereafter at the option nfthe contractOr, Access to the building is implied,
We will INSPECf for rotten wood .al)d REPLACE wood at $ :. f . " per 4' x 8' 1/2" plywood sheathing and $ ~per foot for
fascia buards and rafters, and $ ..~ ,...~~_per fOOl for I" decking EXTRA, All c\lstom wood work. will be: charged at cost plus $25,()() per
man hour. Sign below and reruni white copy.
"\ ,fF
, . ,. I.' -i
Accepted (Own~ *,I.;:.~iu,-
I ban read and understand the above contract and conditions stated on the revene side and 32'ree to same.
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Date :.., ht, ~ ;'.-"1
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Contractor
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Wizard Roofing, Inc.
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Page I of2
5T ATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
. 1940 NORTH MONROE STREET32399 0783
TALLAHASSEE FL-
(850) 487-1395
:~9 0<3 <g ~ azrk.ou..Ziuc! L.p
FRAZIER, WAYNE EDWARD 35'2
WIZARD ROOFING INC
6~ifR TRAIL COURSE FL 34472-2196
'352- 2~(p 470?>
~~o '770., '2
~:36;Z- Co '6-U (0<6 '-{ 6
DETACH HERE
c#27 312 86
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD SEQ#L06081801591
: - LICENSE NBR
)8182006 068031457 CCC1326895
The ROOFING CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2008 .
DATE
FRAZIER, WAYNE EDWARD
WIZARD ROOFING INe
17 FIR TRAIL COURSE
OCALA FL 34472-2196
JEB BUSH
GOVERNOR
DISPLAY AS REQUIRED BY LAW
SIMONE ~_~BTILLER
SECRETARY
STATE 0
DEPA~T~ FLORIDA
DIVISION ~~T OF FINANC
CONSTRU WORKERS' d~L SERVICES
~~W'FICAT~~~~N INDU~:~~SATlON
KERS' COMP XEMPTION F
EFFECTIVE' ENSATION LA~OM FLORIDA
* * EXP~RA~: /26/2006 '
PERSO'" W.::'TE' 07/25/200. . ...
;t:~.""'..r., S::R~r- .5.5 V t\N ~.'E
R "O~md2~.417NTS
,t=JL ~).... . "-
SCOPE _ "" __. 4472 SE
OF BUSIN
1- CERTIFIED ROOFI~~SC OR TRADE:
ONTRACTOR
IMPORT ANT
Pursuant to C
corporation w hapter 440,05(14
certificat ho elects e ), F.S" an '
benefits :r of election un~~mPtion from t~fflcer of a
compensation U:d thiS section ~ chapter by Wi
er this chapter ~y not recover ng a
nlll:C'TlnMC"")
lor:-n\ II"~
ACORD CERTIFICATE OF LIABIJ,.ITY INSURANCE I DATI! (IIIIIDDJVYY
lIf 08123107
PAOClUCIR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIC
One Source Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAi
HOLDER. THIS CERTIFlCA TE DOeS NOT AMEND, EXTEND C
2946 N E 3rd Street Suite 102 ALTER THE COVERAGE AFFORDED BY THE POUCIIS BELO\
Ocala PL 34470 ph#352 671 6718 fx#352 871 6719 INSURERS AFFORDING COVERAGE NAIC.
IHtURiiD WIzard Roofing Inc INSll""RA: Seottec:t8ie InSurance Co
Wayne Frazier IN81JRFFI A:
17 Fir Trail Counse INSUR~ c'
Ocala ilL 34472 INSURGR 0:
INSURJ;;R ~
COVERAQSS
'l'HI$ POLICJI5S 0,. INSURANCI! LISTIID BELOW HAVE BEEN ISSUED TO THE INSU~J:D NAMED ABOVE FOR THE POLlCV PeRIOD INDICATED, NOTWITHSTANDI~
AN'( REQUIREMENT. TERM OR CONDITION OF ANY CONTPlACT OR OTHER DOCUMENT WITH RESPBCT TO WHICH THIS CERTIFICA11E MAY Be. ISSUEO C
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIt!$ Dl!!SC~lno HEREIN IS SUBJECT TO ALL THe ~MS. EXCLUSIONS AND CQNDl'I10NS OF sue
POLICIES. AOOREGATE LIMITS SHOWN MAY HAve BeEN ~CUCiD 8Y PAID CLAIMS.
A.
CLS1409937
7131(07
7(31108
500 000
, 10 000
6000
500 000
s 1 000 000
.. 1 000,000
0IIlI.a IJAItll.lTY
AI<< AUTO
ALl.. OWNE!D AUTOS
$CHEOVLEO AUTOS
HIRGO AUTOS
NOIII.OW~EO AUTOS
COM8INIOIJ ISINCAJi I.IUIT ..
(Id ~nI)
SOOIl. Y INJURY S
cptt "-l
10DIL Y IN.IVRY S
C"r lICGltlW1t)
PROPlSRTY DAMAGE ,
CPet .....dent}
GAlt,AGI UABlLrrY
AtN AUTO
Itl(O~UAIlIU'l'V
OCCUR LJ CLAIMS MADE
~ COMI'INllATION AND
IIMI"L.OYIM'I,JAIIJI.lI'Y
A.tNPROPR~UTIVE
OfllllO&RJMEMKR EXCLUOIOD?
If"" deeci!IH UIlll.r
OTHeR
~Pl1ON OJl' OPaRAllOH1S I L00A1lON8/VIlHIOLU IIXCl..UBIONS ADDIID !IV IINDDftaIMIHT ISPIliClAL PROVISIONS
Wayne Prazler License'" OC01326885
CI!RTfPICATE HOLDER
City of Zephyrhflls
BUlIOlng Dept
5335 8th st
Zephyrhllls, FL 33542
CANCEu.ATION
Ifo/OUL/)/IlHVO...1HtI~0Q0RIllI1KI1"OLlOlU" CANOIII.I.ID..OM THIl QPlMT
OA TIE THIIMOf'. THW II8UltlIO IN8URIIR WII.L BOIlAVOJII. TO IIIAIl. ...!!.... OAYlI WIVT'
NOllC1i TO 'Jt\1iOlMnI'lW,R ttOI.on *'-D TD114IIl.aJIT, .ur "AILUlUi'TO OOlm1tM
JIUIOlII NO ~TIOH OR UMIUTV 01' ANY IQND UPON THE INAl,JJUIR. IT8 AGE,",
ACORD 25 (2001108)
08-20-2007 22:22 WIZARD ROOFIN, INC 352-680-6845
PAGEl
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1lu1o;?,ZG"
Sworn to and subscribed to before m .
Wcu ~ t:.~ . r-' , e thlS 24th day of August 2007 b
~lf"l..e. __,.'oo..n-i 1-V"?\'7IP~ who has produced Florl'da D" Y
. . rlver s License
as ldentlfication and who did not t k
a e an oath.
State of Florida
County of Pasco
c-r-~ d~ ({
Karen Miller ~ ''2 ~ 07
Not~~;y: Public
:~w.l~ Karen L. Miller
~\~ i:i CO":,mlSSion # DD609664
#~iYi~ Expires October 29,2010
.... fit\' NiI\. lMllItIIM, lIIi __till.
NOTICE OF COMMENCEMENT
State of F /0,1 ;;;14 County of n s t.' CJ
THE UNDERSIGNED 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:
1111111111111111I11111111I1111111111111111111111111111111111
2007144064
1.
~ 'T /Z.J
It- J p~/r Pr/() (,
~e l{{.q"7 PC}. 'if
2.
Rcpt: 1124347 Rec: 10.00
DS: 0.00 IT: 0.00
08/24/07 Dpty Clerk
3. OwnerInfonnation: Name Cll'/-y~/) R. h ;ftfl4#
Address ?'7.J~! $~#c:r;bld(f City 0^ytth,1'/r
Interest in Property: 6) wl'Jf IL
State H,
3 35 C( 2
Name of Fee Simple Titleholder:
(If other than owner)
tJ'VI1(',l..
ii92~~~~"Ar0: ~r:;o fOUNT:, C'iERt<
OR Bt< 7612 PG 871
State
~';;,;(' ~(!;
oJ
State pi .3 Y't(7 L
'"
r.t~.
~5
Address City
Contractor: Name 4J~t1~ E. hll'l?~~ ~ MtHJ()
Address 17 Fii h2lf~ '/ (~,.&City ~.J4
~ /11--
/
Surety: Name
~
r1t2-
~
City
State
Address
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 provid by Section 713.13 (1) (a) (7), Florida Statutes:
p
Name
Notary Public:
My Commission Expires:
PC93053048/A
,20n.
< Lu:> LL.
~ cr!:i 0 ;:e
C!lz~:> UJ
~OLu< cj
Ol-ZO I-~
mE5~1- ~ :::>
a:2 0 CL
I?gs:j .S/;:: ~
~Ol:l:: Cl)r =>
t:Luo;r ~
< :r: en I- a:
<cO :r:tz -' t'\I-
OO~OI-< ...
ffCl)i=~!:~ ~
o<a:80-'
...Jo..~I-~5 -'
1.1. 1.1. 0 (.)(~ ~ u
LI. 0 :;; ~ ~ it :i-
0~!Q8io
WZ~G!~z
....::> ~lI.4lt
~O Lu~~ ~
CI) 0 i! a: '< L.U:>
I-Or ~ro
Address City State
8. In addition to himself, Owner designates A/~
of to receive a copy of the Lienor's Notice as
provided in Section 713.13 (1) (b), Florida Statutes.
9. Expiration date of Notice of Commencement (the expiration date is 1 year from the date
of recording unless a differ nt date is specified.)
~'/l-
Signature of Owner: