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Home My WebLink About11-11834 CITY OF ZEPHYRHILLS ` � 5335-8t1a S� t --- � (si3)�so-oo20 11834 > LECTRICAL PERMIT Permit Number: 11834 Address: 38410 6TH AVE Permit Type: ELECTRICAL MISC ZEPHYRHILLS, FL. Class of Work: ELECTRICAL MISC Township: Range: Proposed Use: COMMERCIAL Lot(s): Block: Section: Contractor: BROCK INDUSTRIAL ELECTRIC L Book: Page: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: Improv. Cost: 1,988.00 Date Issued: 5/09/2011 __ Name: ZEPHYRHILLS FIRE DEPT. Total Fees: /--- -40.00 �'�, Address: 38410 6TH AVE Amount Pai ' ZEPHYRHILLS, FL. 33542 Date Pa' : �� Phone: Work Des . ICE METER ELECTRICAL FEE 40.00 ,--- , �, �' � � � ROUGH ELECTRIC CONSTRUCTION POLE PRE-METER FINAL �— ( ( � REINSPECTION FEES: Reinspection fees will comply with Florida Statute 553.80 (2)(c) when extra inspection trips are necessary due to any one of the following reasons: 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. 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." Complete Plans, Specifications and Fee Must Accompany Application. All work shall be performed in accordance with City Codes and Ordinances. (� CON CTOR PERMIT OFFI PERMIT E IRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER t � �� ,. � _ s t a I ��"f�� a � ��sytc'�S'^ �s � J �ys .k` "�';� � � �uF�� s� � 7 � '��' "�" s� �p ... � k �� t �� 'Af � '�u� , i �" ° " rn�` �`` � '*�' `�� , w ,s y �,�.�a^�`�¢ �;.. ,� d t' �: � ,° �," � . 'f.� a �'G�g �, h y.. `p � '� J� , �, 6 . �Sr`��+n x r . . �� 3 �� t �„ a � . . � - ,Y r ~n. ��+�,,,., "'e i �r.1 � lw y�,� z?' ,7` � t ` x � " . . ' . '. ; 'G ,. _. � � � � � � � � � �e Y � �}' ,. w� .P�'� .5 m 'S,. . . � ' � S � �, i �"�'� , � , 4S' "�' �: . � - � ` � �� .��+�k .� � ��t,j� ;: y fi� �� . a 7 � � � � ' �� 'S� � �� i�� k � a .� � '�^ � � �r,� r" «� 1��.� $� } ��t t ' "� �`� > � �ff r'�.. r' � � , � a �d� F '�� °��.� �'''�:+� 3 � � y � �, t �;, � � � � s � ', �� :�, �^� y � �, ,� � .� Ev� y �t . � � � � ; � �'k{� � � �'� y N` ' 1 9�� k '�° . . . J c "� ,��# �,�' �ie t r S� `�x f . t ,fd.`��`,r� �i a�,` F .. . , . .. . d ��F 1. W+�1� a- � � . . f ,� )� �j, 7 � ,' x. .. .. � ' ' „�t � 3 ,�` � a Y � . : - ,-, . �ua! S' `.�'- k ' , . � � T,�e a� p �y y't �,,'." � �� '� �' � �'�'� ' -. � �i �. �"r�� : ,� _ . .`.. � . . :� , r e :: .. � . ,,.� . . . r , :.1'� „_:; . .. � � . � �. �� . . . - � � r �j . . . . . . ... . . � ,. . . . . . � � �� .��E � � � . � � � � . �t` �'� ,��s ��'" ,, �, 3 �. F! . � L �F � i * .. . t � f � V f � � "X . . . . t � �x� � v T �'�r ,� g„ �3 � h �:� I . �; � � .. . - . � � . . . . . , s:�� , u � � .. . . . y ",� � lt� c E � ��$ A a .' r n a s � . . Y W? ��t 7 ��.� 2 � .: ".. ' .., �� C� _ � �' f � , , � . _ ' . . . . � . . � Yn� .. � . AC R � CERTIFICATE DATE(MM/DD/YW� �= OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to tt certifcate holder in lieu of such endorsement(s). PRODUCER Alliance Insurance Solutions LLC PO Box 1777 CONTACT NAME: St Petersburg, FL 33731 PHONE N : �2�-as�-�2a� Fn ac No: 727-497-12F E-MAIL ADDRESS: INSURER S AFFORDING COVERAGE NAIC il iNSUReRa: SUNZ Insurance Com an 3q�6z INSURED Convergence Employee Leasing, Inc. Convergence Employee Leasing II, Inc INSURERB. 8777 San Jose Bivd #402C INSURER C Jacksonville FL 32217 INSURER D INSURER E : INSURER F . COVERAGES CERTIFICATE NUMBER: 10100105 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIC INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP - GENERAL LIABILITY MM/DD MM/DD LIMITS EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP (My one person) $ PERSONA� 8 ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PR � LOC PRODUCTS - COMP/pP AGG $ AUTOMOBILE LIABILITY S COMBINED SINGLE LIMIT ANY AUTO Ea accident $ ALL OWNED 8 SCHEDULED BODILY INJURY (Per person) $ AUTOS AUTOS BODILY INJURY (Per accident) $ HIREDAUTOS NON-OWNED AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR $ EXCESS LIAB EACH OCCURRENCE $ CLAIMS-MADE _ AGGREGATE $ DED RETENTION $ $ $ /� WORKERS COMPENSATION WCPEOOOOOO4ZO'I / WC S TU- O�tl- $ AND EMPLOYERS' LIABILITY 7/�/ZO1 O 7/I/ZO� � � TORY IMITS rt ANY PROPRIETOR/PARTNERlEXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? ❑ N/ A �_ _ E.L. E ACCIDENT $ 'I OOC (Mandatory in NH) If yes, descnbe under ---- -- --" E.L. DISEASE - EA EMPLOYEE $ �� DESCRIPTION OF OPERATIONS below __ E.L. DISEASE - POIICY LIMIT $ 'I OOC DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (Attaeh ACORD 101, Additional Remarks Sehedule, if more spaee is required) Coverage provided for all leased employees but not subcontractors of: Curt Brocklesby Location coverage effective: 7M/2010 CERTIFICATE HOLD R CANCELLATION 460 City of Zephyrhills SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOF THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. Fa� 813-780-0021 5335 8th St AUTHORIZED REPRESENTATIVE Zephyrhills FL 33542 �� , ,� / �� .G ,,7 _ � � c.. Glen J Distefano wnnnn �e i�n�r��e�� OO 1988-2010 ACORD CORPORATION. All rights resen r�.., wrnon ......... ....a �....., _�.. �.......�..�..a .«...�.. ..c wnnnn .,..�.,,. .......,�.. v......� ��It � BROCK Ii�U.:7'FRtAL ELECTR�, LLC Date: 5/2/11 To: City of Zephyrhills Building Dept. Re: Contractor Certificate The following is (are) authorized to sign for and pick up building permits for Brock Industrial Electric, LLC: 1 Curt Brocklesby Than u, �� C rt Bro lesby, President (MGR MBR) Broc ndustrial Electric, LLC ��''-�� ,�� - _ ��.�� - � - � � � .h �a,� � �" � � �.� - :�S� A '��, 9C�fE S. SWETLAND _►: ,.__ Ct�fP1h11bsiart OD 734406 =��.� = Expires February 22, 2012 Rf �fi� ea+�oa tniu rrq r�r, mn.a,,,e eoo3a,s��o,s P.O. Box 2344 Winter Haven, FL. 33883 Phone (863)307-9016 Fax (863) 318-9025 www. brockindustrialelectric. com " � - e �, V T +f � �.. ` R{ � � � : . r � ..<o r� .� �� .. � i � � . u.�, r ' � j . - r ,.: ' t � ', fi >� �.S �+ fi y'�� * � ��,. 1 • �� .� j �'s � ��'� � , s � r . . . .�.¢aua'� . ,�:.ir. .�;f�k'u S �'ur �-,� 4 � r A �.� . � t� , � . . p ,:�� i 1 n ;. G } 'k !J`s�� f,` �`� Y ��.r � i� $ g s t�` ��`��' � " a � f r w�ia"�' � i� f�4" r. . . � _ , � ,� r �r �+ F . �`C ' . . � .. � S �F, i � �r . . ��J �` 'Af" . i { . y j ,�,� �r � p '�,kp"i,�y'�q _ �: . . 5�� a 9 yg �� '� — . . � 3 tdEM {� �M1t .^�- }� � � � � . { � . . fr �^�� t ��K`�... " 9' ��,�,� . .. � r ,� � �a�� 3 � ::. � �� '� � �� « a� � y� �"�S? ; . . d _+�� Ry � �, ..� v " � ` fi � � 7 � y y � � . . - - - [ �� ft fi� w y ' 4 '' � � '4'�1 . �.: r � �l +� a ��?'� �_"4 X+��'{i "� t "��'-i � _�''s$ /, 1 � . . . � � . .. � �"� ��; ' �: } ; . � � � �f >�.°`E� '�+,`: � ,3.,� r � �. � - � . . �� 1 . 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'� 2 � ,ry ,� . . . . .. >'� � n �s5 a F�,J..� i ':.. �� *�' y d ,, �: ` � � � ,�p � r �.'�� . . � � ' k'��, i� . . � �,� 6r �; � � s� `»� -��: � � at � .� �. �� . � . . � ' i � '� .. { �J �S j� k �* / i �i � ip�YMn ",� � � t '��h''3t� SYd��'� �:7rf"�� . .. � � Se1,? r.l ?Y �' e ��'4.'yS;° � i r.M 'Y '� ; ' ,. � � 4 �� 3" �s.? Y. [ . . � .. . r✓�'�'� re e . '�_� A �� , � ��r� �� y � : ��`+�P�� +� 7 . � �.k' � � �+ �. �. z �. F ; . . � �' ` 7' ;�. . < � w�� y�` '�"�'�� A � {r t � - w a � �v�� '" 3.� �C � y '�c �. �, ' ,�>, } �' � Lt � A. 1 �. �` �` 4 '� l'� a 4y . �;��'!`'�#� �„�' e, - ,��71'� �,. � w � '�'� r r � ; � � �rk� ��'tTSC� r��s'�`�� F '�"�x'�*� X {' C` � v� i �. 3 �. � � � _A� .a,"»\ f �� -; . � �� ., i.a ��` ;$ � �''��..? �. £s {;: '� rc� , �`il .� k i* �" , � s ,� �s' ''�t. `p ��: `�. �`" � �"� wF � , �� k �+ . , . . �, . . � �r " °� � � �` � } , t�` � F� ,.w.. ,� ;•i ;. � t h �' ,',� � , '��i;: �rrs� ��. . : i ��{ ,( j : `-r From:Michelle Hall FaxID:86?-967-7592 Page 2 of 2 Date:05/02/11 10:52 AM Page2 oi 2 , �� ACORO" OP ID: MH �-- CERTIFICATE OF LIABILITY INSURANCE o^T�{MMroonm�� OS/02111 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAIIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIqES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSIITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S� AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certfficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, aubject to the tertns and conditions of the policy, certain policies may require an endorsemerrt. A statement on this certificate does not confer rigMs to the certificate holder in lieu of such endorsemertt s PRODUCER 863-967-0454 �«dTACT Mulling Insurance A enc , Inc. """" P O Box 308 208 E Park Street 863-967-7592 PHO^� F,ix !C No Ext : AJC No : E�AAIL Aubumdale, FL 33823-0308 noor�ss: Jim Mullin PROOUCER gROC-03 g CUSTOMER ID t: INSURED INSURER�S) AFFORDING COVERAGE NAIC i Brock Industrial Electric, LLC INSURERA Auto-Owners Insurance Co. �gygg Curt Brocklesby INSURERB Western Sure Com an 189 Lagoon Rd. 13188 Winter Haven, FL 33884-2564 INSURERC INSURER D INSURER E INSURER F . COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LiMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER MMAD MMAD� LIMRS GENERAL LIqBIIITY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO�OO 72685037 07/03/10 07/03/11 pREMISES Eaoccurrence s 300,00 CLAIMS�v1ADE C] OCCUR MED EXP (My one person) $ ��QQ x N&NOA:1000000 PERSONAL&ADVINJURY $ ��OOO�OO GENERALAGGREGATE $ Y�OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER POLICY PR � LOC PRODUCTS-COMP/OPAGG $ Z,OOO�OO AUTOMOBILE LIABILITY $ COMBINEDSINGLELIMIT $ ANY AUTO (Ea acadenq ALL OWNEDAUTOS BODILY INJURY (Perperson) $ SCHEDULED AUTOS BODILY INJURY (Per acadent) $ H IR ED AUTO S PROPERTY DAMAGE (Peracade�t) $ NON-OWNED AUTOS $ UMBRELLA LUIB $ OCCUR ExCE3S LWB EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE g DEDUCTIBLE RETENTION $ $ VMOPoCERS COMPENSATION $ APD EMPLOYERS' LIABILI7Y WC STATU- OTH- ANYPROPRIETORlPARTNERIEXf:CUTIVE Yf N TORYLIMITS ER OFFICERMIEMBER EXCLUDED� � N/ A E L EACH ACCIDENT $ (Mandatory In NH) If yes, desrnbe under E L DISEASE - EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below B License & Permit 2484��4 E L DISEASE- POLICY LIMIT $ 10/28/10 10I28171 Bond 5,00 DESCRIPTION OF OPERATIONS 1 LOCATION3/4EHCLES (Attaoh ACORD 101, Additlonal Remarks 3chedule, i/moro spacs is rsqulrod) Electrical work - with-In bldgs. CERTIFICATE HOLDER CANCELLATION CITYOZE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN City of Zephyrhills ACCORDANCE WITH iHE POLICY PROVISIONS. Building Department 5335 8th Street AUTHORIZED REPRESENTATIVE Zephyrhills, FL 33542 (►,�;,_ rn„a�-�.�, �'iL/rI/ AA�i��i�a.�, V O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 813-78U-Up20 City of Zephyrhills Permit Application Fax-813-780-0021 Building Department . r Date Received 5- 2� � � Phone Contact for Permittin �le�j 3 p� _ �� — Owner's Name � � � ( Owner Phone Number ��5�? �O - 0000 Qwner's Address �j ?j3r �` Owner Phone Number � / Fee 5imple Titieh �' Owner Phone Number �---�� , Fee Simple Titlehotaer Address JOB ADDRESS � � Q '�'�'` L �� LOT # SUBDIVISION , PARCEL ID� (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED NEW CONSTR ADD/ALT C� SIGN Q [� DEMOLISH B INSTALL 8 REPAIR PROPOSED USE � SFR Q COMM �� OTHER TYPE OF CONSTRUCTION [� BLOCK Q FRAME [-] STEEL Q DESCRIPTION OF WORK - � .� ` e BUILDING SIZE SQ FOOTAGE�� HEIGHT QBUILDING $ VALUATION OF TOTAL CONSTRUCTION �ELECTRICAL $ AMP SERVICE f-1 PROGRESS ENE I 9�S$ .00 L---� � W.R.E.C. QPLUMBING $ � /�� 1 QMECHANICAL $ VALUATION OF MECHANICAL INSTALLATION [�GAS Q ROOFING Q SPECIALTY � �� OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA QYES NO BUILDER COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N Address � License # ELECTRICIAN � COMPANY ��'O� � a(u5�f IA.� � GLTrIC. L,L SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N Address License # � Ob0 'L ( ''�'l PLUMBER COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N Address License # MECHANICAL COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N Address License # OTHER COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y! N Address License # 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 w/ Silt Fence installed, Sanitary Facilities 8 1 dumpster; Site Work Permit for subdivisions/large projects COMMERCIAL Attac�h (3) complete sets of Building Plans plus a Life Safety Page; (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 w/ Silt Fence installed, Sanitary Facilities & 1 dumpster. Site Work Permit for all new projects. All commercial �equirements must meet compliance SIGN PERMIT Attach (2) sets of Engineered Plans. "'"PROPERTY SURVEY required for all NEW construcUon. Directions: Fill out appiication comp�etely. Owner 8 Contractor sign back of application, notarized If over $2500, a Notice of Commencement is required. (A!C upgrades over;7500) '* Agent (for the contractor) or Power of Attomey (for the owner) would be someone with notarized letter from owner authorizing same OVER THE COUNTER PERMITTING (Front of Application Only) Reroofs if shingles Sewers Service Upgrades A/C Fences (PIoUSurvey/Footage) 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 rest�ictive 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 locai 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 IMPACTIUTILITIES 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 a�so 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 cer#ificate 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'SIOWNER'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 cvnstruction, 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 I 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 8� 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 �II 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 apptication. 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 is considered abandoned. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR WITH YO R R OR AN A'RORNEY EFORE RECORDING YOU 'N OT CE o COMMENCEM�NT. � CONSULT FLORIDA JURAT (F.S. 117.03) OWNER OR AGENT CONTRACTOR Subscribed and swom to (or affirmed) before me this Subscribed and s �(or a rme efore this by ° bY Who islare personally known to me or has/have produced o is/are personally known to me or has ave prod as identlfication. Y�� -�� as identifi n. ,�� ,� �' ., .l Notary Public ry Public Commission No. Commission No. Name of Notary typed, printed or stamped , ND Name of Not ; � :.: :k: Commi�sion 00 734406 ;?� a: Exp�ras February 22, 20i2 "�IR„��c°�� 6oMed Thru 7roy Fan Insurar�ce 800.3857019