HomeMy WebLinkAbout12-12679 CITY OF ZEPHYRHILLS
5335-8th Street
' � (813)780-0020 12679
ELECTRICAL PERMIT
Permit #:12679 Issued: 1/06/2012 Address: 4900 5TH ST
Permit Type: ELECTRICAL MISC ZEPHYRHILLS, FL.
Class of Work: ELECTRICAL MISC Township: Range:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Sq. Feet: Est. Value: Book: Page:
Cost: 249.00 Total Fees: 60.00 Subdivision: MOORES FIRST ADDITION
Amount Paid: 60.00 Date Paid: 1/06/2012 Parcel Number: 14-26-21-0010-01500-0150
Name: ADT SECURITY SERVICE, INC Name: TOOMAJIAN, KIRK & ANGELA
Addr: 5471 W. WATERS AVENUE, STE 1000 Address: 4900 5TH ST
TAMPA, FL 33634 ZEPHYRHILLS FL 33542
Phone: (813)806-7000 Lic: Phone: 813-783-6618
Work Desc: INSTALLATION LOW VOLTAGE SECURITY SYSTEM
ELECTRICAL FEE 60.00
ROUGH ELECTRIC
CONSTRUCTION POLE �
PRE-METER
FINAL , y�-�
l� � _ 7%( �_
REINSPECTlON 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 consd�uction c) repairs or corrections not made when inspection called d) work not ready for
inspection when called e) permit not posted on job site � 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.
"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.
- ------- �
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COf��CTOR PER OF I
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
s�s-�eo-oozo City of Zephyrhills Permit Application Fax-813-780-0021
Building Department
Date Recetved fJ' _ � � -- � phone Contact for Permtttin � � -- / l� ! �
Owner's Name T��MfI'��A.�.� �/Lyl -e /Qti(o �.;� /`� Owner Phone Number � / � ! �� �
Owner's Address 7 � ! l�J �'� � ,C / �' . ' / ! ( J� Owner Phone Number
Fee Simple Titleholder Name Owner Phone Number �
Fee Simple Tftleholder Address
JOB ADDRESS J�H �- Z� j -� S7 � LOT # �
SUBDIVISION PARCEL ID# / -2 � /- ��f ��- o l So �- o C T�
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED w CONSTR ADD/ALT � SIGN Q [] DEMOLISH
INSTALL 8 REPAIR
PROPOSED USE Q SFR Q COMM � OTHER
TYPE OF CONSTRUCTION Q BLOCK Q FRAME � STEEL Q
DESCRIPTION OF WORK � j � �, � , � � � v z • ,S �' .;
BUILDING SIZE SQ FOOTAGE � HEIGHT
QBUILDING $ VALUATION OF TOTAL CONSTRUCTION
DELECTRICAL $ C p_ AMP SERVICE 0 PROGRESS ENERGY Q W.R.E.0
l
QP�UMBING $
.�� �,� 7 �
QMECHANICAL $ VALUATION OF MECHANICAL INSTALLATION
QGAS Q ROOFING Q SPECIALTY 0 OTHER
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA QYES NO
BUILDER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N
Address License # �
ELE TRICIAN COMPANY A I'J 7 ,� L. C-c..� �'(, ( T� S� �I, 1� � C' � 1
SIGNAT REGISTERED Y/ N FEE CURRE� Y/ N
Address ,S / �•c./. �t1 � 7`f1�� �.; - ( �Q License # � � f� � .� l � Z�
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. Requfred onsite, ConstrucGon Plans, Stormwater Plans w/ Silt Fence installed,
Sanitary Facilities & 1 dumpster; Site Work Permit for subdivisions/large projects
COMMERCIAL Attach (3) comptete 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 WoMc Permit for all new projects. All commercial requirements must meet compliance
SIGN PERMIT Attach (2) sets of Enaineered Plans.
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 th� 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 constructio�, 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 Environmentalty 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 �II 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 IN YOUR
PAYING TWICE FOR IMPR N ATTORNE YBEFOREROPERTY. IF YOU INTE CE OF COMMENCEMENT.' CONSULT
WITH YOU
FLOR RAT (F.S. 117 3) — _
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Pasco County Parcel: 14-26-21-0010-01500-0150 001 Page 1 of 2
Data Current as Of: Weekly Archive - Saturday, December 31, 2011
Parcel ID 14-26-21-0010-01500-0150 (Card: 001 of 001)
Classification 01 - Single Family
Mailing Address Property Value
TOOMAJIAN KIRK & ANGELA Ag Land $p
4900 5TH ST Land $22,440
ZEPHYRHILLS FL 33542-5700 Building $83 964
Physical Address Extra Features $13,706
4900 5TH ST
ZEPHYRHILLS FL 33542 Just Value $120,110
Assessed (Save Our Homes) $120,110
Homestead 196.031 - $25,000
Legal DesCri tion (First 4 Lines) Non-School Additional Homestead Exemption -$25,000
MOORES AD MB 1 PG 57 Non-School Taxable Value $70,110
L15, 16 BLK 15 School District Taxable Value $95,110
RB 899 PG 1424
Warning: A significant taxable value increase may accur when sold.
Click here for details and info. regarding the posting of exemptions.
Land Detail (Card: 001 of 001)
Line Use Description Zoning Units Type Price Condition Value
� 0100 SFR OOR3 13,200.00 SF $1.70 1.00 $22,440
Additional Land Information
Acres 0.30 Tax Area :�{)Zl��i FEMA Code AE Residential Code ZHLGLP7
Building Information - Use 01 - Single Family Residential (Card: 001 of 001)
Year Built 1988 Stories 2 0
Exterior Wall 1 Concrete or Cinder Block Exterior Wall 2 None
Roof Structure Gable or Hip Roof Cover Metal
Interior Wall 1 Drywall Interior Wall 2 None
Flooring 1 Cork or Vinyl Tile Flooring 2 Carpet
Fuel Electric Heat Forced Air - Ducted
A/C Central Baths 2.0
Line Description Sq. Feet Repl. Cost New
1 BAS -� 1,269 � $53,996
2 FEP 285 $8,510
�3 �� UST � 240 $4,085
4 UGR 576 $7,361
5 FSA 84 $1,234
6 FUS 816 $31,232
Extra Features (Card: 001 of 001)
Line Description Year � Units Value
1 FIRE PL 1988 1 � $960
2 DWC 1989 768 $874
3 UDU-M 1988 1 $192
�4 COOL DK 1994 1,124 $3,118
5 POOL=6 1994 450 $5,400
6 JACUZZI 1994 1 $600
7 DCFENCE 1994 912 $341
$ SCRN-AF 1994 2,q6g $2,Z21
Sales History
http://appraiser.pascogov.com/search/parcel.aspx?sec=14&twn=26&rng=21 &sbb=0010&bl... 1/3/2012
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14(�43 1000' RL ; 14009T 500' BX Detector
14310$ 22 2• 7 X 30 GRAY .155" Magnetic stripe reader ; 454650AWH 22 4 7 X 30 WHITE .139"
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RESIDENTIAL SERVICES CONTRACT �
5104UE12 �
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GONTRACT I CUSTOMER JOB � LEAD � �
DA7E L��'t I�� ACCOUNT NO • NO SOURCE �
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ADT Seturity Services, Inc (`ADT") �ytomer Name �
Offlce Address ('�ustomer" a"I" or "me' or "my') j
—�ls'�t� �,�=�.,9�' !
5 �°�`��' � i
,�i�!��� ��h•7��'Address �
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i Siate � ZIP 1�1�r�� Tax Exempt No. i
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Protected Premises' ����///��,�"""
� Telephone �!�� Tax Explre Date i
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ci�Traditional Phone O Other (Qualified) O Other (NonQualifled) I
www.MyADT.com �
1.800.ADT.ASAPm Rlternate �
(1.800.236,272� � Telephone 1 O Home C�►Cel1 O Work i
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IF FAMILIARIZATION PERIOD IS � Altemate �
/'1 REJECTED INITIAL HERE Telephone 2 C7 Home O Cel! Owork f
t J (see Paragraph 14 of the Term: and i �
� Conditions for explanation) EMAIL
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� Communications AuthorizatiOn: I authorize ADT to provide me with information and updates aboutthe security system and new ADF and third-party I
products and services to the contact information provided by me. I may unsu6scri6e or opt out by ema(Iing donotcontaR�ADT.com or by calling �
888.DNC4ADT (8883624238). Initial here �
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ConNrmation of AppoiMmeMS; I authorize ADT to ca11 me using an automated calling device to de�nrer a pre-recorded message to seVconfirm �
�� appointmerrts and provide other irrFormation and notices about xhe alarm ryrtem at the telephone number(s) provided by me. Initial here I
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Alarm System Ownership: � CustomervOwned � ADT-Owned �
�
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I ACKNOWLEDGE AN6 AGREE TO EACH OF THE FOLLOWING: (A) THIS COIYTRACT CONSISTS OF SIX (b) PAGES. BEFORE SIGNING THIS CONTRAG7,1 I
n HAYE READ, UNDERSTAND AND AGREE TO EACH AND EVERY TERM OF 7HI5 CONTRACT, INCLUDING BUT NOT UMITED TO P1iRAGRAPHS 5 AND 18 OF I
\! � TNE TERMS AND CONDffIONS. (B) THE INITIAL TERM OF THIS CONTRACT 15 THREE (3) YEARS. (Q ADF IS NOT A SECURRY CONSULTANT AWD CANHOT I
V ADDRE55 ALL OF MY POTENTIAL SECl1RITY NEEDS. ADT HAS EXPLAINED TO ME THE FULL RANGE OF EQUiPi1AENT AND SERYICES 7HA7 AD7 CAN �
1 PICOVIDE ME. qDpRIONAL EQUIPMENT AND SERVICES OVER THOSE IpENTSFIED !N THIS CONTRACI' ARE AVAILABLE AND MAY BE PURCHASED FROM i
�J ADT AT AN ADDITIONAL COST T6 ME. I HAVE SELECTED AND PURCHASEp ONLY THE EQUIPMENT AN� SERVICES iDE1dT1F1ED iN THIS CONTRACI; (D) NO I
_\ AtARM SYSTEM CAN PROVIDE [OMPLETE PRO7'ECTION OR GUARAMEE PREVENTION OF LOSS OR iNJURY. FlRES, FLOODS, BURylARiES, ROBBEpIEi, I
�� MEDICAL PROBLEMS /YNO OTHER INCILIENTS ARE UNPREpICfABLE ANp CANNOT ALWAYS BE pEfEC'[EQ OR PREVENTED BY AN ALARM SYSTEM. I
�'� HUMAN ERROR IS ALWAYS POSSIBLE, AND THE HESPONSE TIME OF AOLICE, FlRE /WD MEDICAL EMERGENCY PERSONNEL IS OUiSIOE THE GOWTRO� I
� OF ADT. ADT MAY NOT RECEIVE ALARM'SIGNALS IF COMMUNICAT10N5 OR POWER IS INTERRUPTED FOR ANY RFASON, (E) ADT RECOMMENDS 7HAT 1 l
MANUALLY TEST THE ALARM SYSTEM MONTHLY APID ANY TEME I CHAtdGE TELEPHONE SERVICE, BY CAWN6 1.SOO.ADT.ASAP OR BY LOGGING IN TO f
WVYW.MYADT.COM. (fJ THtS CONTRACT REQUIRES FfNAL APPROVAL BY AN ADT AU7HORIZED MANAGER SEFORE ADT MAY PROVIDE ANY EQUIPMENT i
OR SEitVICES, AN6 IF APPROVAL IS DENIED, THEN THIS COI�TRACT YUILL SE TERMINATBb, AtJD ADTS OIdLY OQLIGATIOl1 WILL BE 70 NOTIFY ME Of I
�� SUCH TERMINATION AND REFUND ANY AMOUNTS i PAID IN ADVANCE. �
� ADT Representative Name � i
� � Rep. License No. Re �. ?�/♦ I
� �� � (tf Repuired? tD Ido. ����Q� t '�•�
� Customer's Approva�: Origlrial Signature Required (Nlust mat� Cusmmer IVame in Sectlon 1 abm�+e) f � ' !
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NOTICE OF CANCELLAT10111 �
1, THE CUSTOMER, MAY CANCEL THIS TRANSACTION AT ANY TiME PRIOR TO MIDNtGHT OP THE TH1RD BUSINE55 DAY j
APTER THE DATE OF THIS TRANSACTION. 5EE THE,pTTACHED NOTICE OF CANCELLATION fORM POR AN EXPLANATION I
Of THIS RIGHT. I ACKNOWLEDGE. BEING VERBALLY INFQRMED OF MY RIGHT TO C,4AICEL AT THE TIME OP EXECUTION i
OF TH15 CONTRACT AND RECEIPT OF THiS NOTICE. �
• • • • • • j
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FiNANC1AL DISCLOSURE STATEMENT
�!__ THERE I$ NO PINANC C HARGE OR C OF C REDIT'(0 % APR) A SSOQATE D WITH T HIS CO NTRqCT, 1
A: N�MBER OF � /{� y /���"� ,y ��. - J
PAYMENTS FOR THE , g,��NT OF EACH PAYMENT IS ��� f � TOTAL Of PAYMENTS FOKTHf INITtAL TERM IS ��L� v� I
INITIqL TEAM IS 36. �(rOTAL MONTHLY SERVICE CHARGE FROM BELOUVh � T��ES 8.) (EXCLUSlVE OF ANY APPLICABLE TAXES, FEES, F1NE5 I
�______ { AND RATE INOtEASES} �
LA1'E CHARGE-PAYRAFNT IS DUE PURSUANTTO MY SELECTED BIWNG -�� � � �
FREQUENGY, PRIOR TO THE STqitT OF SERVICE MY FlRST BIWCHARGE WILL i PREPAYMENT - IF I PREPAY THE � SEE SECTIONS 2, 7, 15 AND �
BE SENT/MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IIIAPOSE A 7aTAL aF PAYMENTS PRIOR FO � 19 OF TH{S CONTRACT FOR �
ONE-TIME LATE CHARGE ON EACH PAYMENT THAT IS MORE THAN TEN (10) ZHE END OF THE INFi1AL TERAA � AppITIONAL lNFOIiAAA'11pN
DAYS }'AST DUE, UP TO THE MAXIMUM AMOUNT PERMITfED BY U►W, $UT �N OF THIS CONTRACI;'THERE t5 NO ABOUT NONPAYMENT, DEFAULT �
NO EVENT WILL TH[S AMOUNT EXCEED�S5.00. 4 PENIALTY OR REFUND. . ANO A[6ELERATION. i
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�� ° SOUND & SECURITY CABLES � I
� C� � SOUND & SECURITY CABLES cMP
� NON-PLENUM ASTM Bare Copper � PLENUM ASTM Bare Copper
High Grode PVC Insulation Premium LS PVC Insulation
i l,� Aluminum Polyester Foil Shield with drain Twisted/Cabled Conductors
i Twisted/Cabled Conductors Plenum Rafed LS PVC lacket
Riser Rated PVC Jacket
, '� • 1 1 � 1 1 1 1 1 1' 1 1
i�
' ADT SQI N0. Oi JAIXET & NOM POSSIBLE USE ` ADT SCN AW � N0. OF S �� p JACKET 6 NOM POSSIBLE USE
� PAIGE PN AW � PAIRS S �� PACI(AGE O.D. & APPLICATIONS PAIGE PN COND. PAtl(AGE O.D. 8 APPLI(ATIONS
� � 145337 24 2• 7 X 32 GRAY 190" Communication Cable 494463 22 4• SOLID WHIiE .122" Contad
140043 1000' RL ' 14U092 500' BX Detedor
k' 74310i 22 2• 1 X 30 GRAY 155" Magnefic stripe reader � 454650AWN 22 4 7 X 30 WHITE 139"
, i 1000' BX to micro-conholler. 1000' BX
' 494415 22 2fl SOLID WHITE .UO" Communicatian Cable � 45465?AWHA 22 6 7% 30 WHITE .227" Unshielded Readers
' i 740029 500' RL '�'" 4�S�py�{ 1000' BX
743106A 20 40 7 X 28* GRAY .299" Weigand reader io 494469 22 12 SOLID WNITE .186" Unshielded Pnnel
� I 143106 1000' RL micraconfroller. 7412S1 500' RL Interface
� 7418D3EPR 18 3• 7 X 26 GRAY W/ .360" Reader mble � 454653AWH 22 12 7 X 30 WHITE .211 °
i RE STRIPE 1 D00' RL
!I
1000' RL 454919AWH 22 20 7 X 30 WHITE .263"
�,fl 500' RL
I p 14186RPL 18 2 7 X 26 WHIT�E PE .150" D � o mera Power
��
1000' RL
,�� 454644AWH 18 4 7 X 26 WHIiE .185" Motion
�
. , . � . , � � � 1000' RL Requesf to Exit (REX)
454694AWH 16 2 19 X 29 WHITE .110" [omera Power
144006A 24 20 7 X 32 GRAY .330" R5485 Panel 1000' RL Lak Power
144006 500' BX Communicafion
140060 24 2 7 X 32 PURPLE .253" Uock (uble
' I 1000' RL CL3P
I ! (ondudor wlor code charis on page 8. � � � , � � ,
I • Code i [ode 6 •(ode 12 O Code 13 O Code 14 �(ode 15 �
'Tinned Copper � 454696AWH 14 1 19 X 26 WHITE .213" Lotk Power
� � 1000' RL C(TV Power
� I I 454b96AWNL 14 2 19 X 26 WHITE .y13^ (or Camera Power)
i i , i 500'
I i� BX OR RL
i', Condudor cdor code l. (hurts on page B.
� '„ � • Code 10
•� � 2 DON'T SEE IT? CALL 1-888-423-8947 z _
DON'T SEE IT. FAX 908�878860
.
� �13
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9
, ' `�� 'y . �
City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contractor/Homeowner: �-,� � �?C.� ,� ���
Date Received: � - ,3�- � 2
Site: �.q � � ��� ��
Permit Type: l� L,�� (•� (� I (� �
Approved w/no comments Approved w/the below comments: ❑ Denied w/the below comments: ❑
This comment sheet shall be kept with the permit and/or plans.
�' `-� �
Kalv' wit - P Examiner Da e Contractor and/or Homeowner
(Required when comments are present)
--------------------�
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� � . , -�--�`�� ����-�� i����������i1i���� �
RESIDENTIAL SERVICES CONTRACT �
5104UE12 �
I
CONTRACT ����j�� CUSTOMER JOB � LEAD � �
DATE � 4�J� i� y i ACCOUNT NO � NO SOURCE �
� � • I
ADT Secur'rty Services, Inc. ("ADT") I�omer Name �
Offlte Address �(•Customer' or "E" ar'me" or'my") �
-��"/!'� Gt,�}.�.�� �
i
�
5T p f''�D !
� � ���Addrcn �
TTG- �/17�i'�� � Cnv I
�f�l��"���"�/ I 'State LL�' ZIP � �
i Tax Exempt No. �
� Proteded Premises' ���
I
1 Telephone •/�� Tax Expire Date m� �
/ ' �
I
�Trad'Rional Phone O Other (Qualifipd) O Other (Non-Qua(ified) I
www.MyADT.com �
1.800.ADT.ASAP• Akernate
(1.800.238,27Z� � Telephone � O Home �Cel1 O Work �
�
]F FAMILiARIZATION PERIOD ISI Alternate j
/'1 REJECTEDINfTIALFlERE Telephone2 OHome OCefl Owork �
� J (see Paragraph 14 of the Ternss and �
� Conditions tor explanation) E ��� I
I
I
� .Communicaiions Authorization: 1 authorize ADT to provida me with infortnation and updates about the secuMty system and new ADF and third-party i
products and xrvices to the contact fnforrnation provided by me. 1 may unsubsaibe or opt out by emailing donatrarrtact�AUT.mm or by calling �
888.DNC4ADT (888,362.4238). Initfal here �
� �
Conflrmation of AppoiMmeMS: I authorize ADT to wll me using an automated olling device to deliver a pre-recorded message to xUconflrm i
� f appoi�tments and provlde other irrtormation and notices about ihe alarm rystem at the telephone number(s) provided by me. Initial herc I
`l �
� Alarm System Ownership: O Customer-Owned � ADT-Owned I
- — ----- ---- -- - I
I
I AQCNOWLEDGE AND AGREE TO EACH OF THE FOLLOWING; (A} TH15 CONTRACT CON515T5 OF SDC (6) PAGES. BEF�RE SIGNING THIS GONTRACT,.I I
/'� HAVE READ, UNDERSTAPID ANO AGREE TO•EACN pND EVERY TERM OF Tt115 CONTRAC7; INCLUDING BUT NOT UMITED TO PARAGRAPHS 5 AND 18 OF I
V � TI1E TERMSAND CONDfTIONS. (B) THE INITIAL TERM.OF THIS CONTRACT 1S THREE (3} yEqR$, (Q qpT IS NOT A SKUWTY CONSULTANT AND CANNOT I
ADDRESS ALC OF MY POTENTIAL SECURITY NEEDS. ADT HAS EXPLAINEO TO ME 7HE FULL RANGE OF EQUtPMENT AND SERVICES THAT ADT CAN I
1 PROVfDE ME. qDORIONAI EQUIPJNENT AND SERVICfS OVER THOSE IpEN77R� IN THIS COMRACT ARE AyA1WgLE AND MAY BE PURCHASED FqOM I
v ADT AT AN ADORIONAL COST TO ME. t HAVE SELECTED AND PURtNASED ONLY THE EQUIPMENT AND SERVKES IDENT1FlED IN THIS COriTRACT. (D) NO 1
` 1 ALARM SYSTEM GW PROVIQE COMPLETE PFtO'lECT10N OR GUARANTEE PR#VENTION OF LOSS OR INJURY. RRES, FLOODS, BURytAR1E5, ROBBENIES, �
��� MEDICAL PROBLEMS /�ND OTHER 1NGDENTS ARE UNPREpICTABLE ANp CANNOT ALWAYS BE DEiEREq OR PREVENTED BY ADi AWiM SYSTEpIt. I
`� HUMAN ERROR IS ALWAYS POSSlBLE, AND THE RESPONSE TiME OF POtJCE, FlRE AND MEDIGLL EMERGENCY PERSONNE�. IS OUTSIDE THE CONTRO{. I
I�� OF ADT. ADT MAY NOT RECEIVE'ALARM'SIGNALS IF COMMUNICAFIONS OR POWER IS IMERRUPTED FOR ANY REASON. (� ADT RECOMMENDS THAT 1 1
AAANUALLY TEST ALARM SYSTEM MONTNLY AkD ANY TtME I CMANGE TElEPHONE SERYiCE, BY CALIJN6 1.800.ADT.ASAp OR BY IAGGING EN TO I
�/ W W W.MYADT.COM. (t� THIS CONTRACT REQUIRES FINAL APPROVAL BY AN ADT AU7HORIZED MANAGER BEFORE ADT MAY PROVIDE ANY EQUIpMENT 1
� ON SERVICE5, AN6 IF APPROVAL IS DENIED, THEN THIS �ONTRACT WILL 8E TERMINAT6D, MfD ADTS ONLY OqLIGAt70N WILL BE 70 #ICTIFY ME OF {
SUQ! 7ERMINATION AND RERIND ANY AMOUNT51 PA1D IH ADVANCE. �
I
ADT Repreut�tive Name � �
�((�� Rep. License No. R i. ?�' /♦ I
� _ (H Requlred} ID No. �'�rQ�r K.� �
� Customer"s Approval: Oriqinai Signature Reyuirod (Mast matdi Custoiner Name In SeWm t ab e) i � ' I
TS=CL � r.s� .,fy,�c/ �/ L'�V�1'X i j
ALL W0� NOTiCE OF CAMGELLATION �
PREVAI ' ���'�� TRA� AT, ANY TTME PRIOR TO MIDNtGHT OF THE THlRD BUSINE55 DAY i
ON. 5EE THE,pTTACHED NOTICE OF CANCELLATION FQRM FOR AN EXPLANATIDN I
CODE, �� �HG VERBALLY INFQRl1AED OF MY R1GHT T0 CANCEL AT THE TtME OP EXECUTION I
C�TY O ���.OF THIS NOTICE.� �
1
• • - • • � �
FINAN[IAL DISCLOSURE STATfMENT �
, V 'THERE IS NO FiNANCE GHARGE OR GOST OF CREDff'(0% APR} ASSOQATED WITH THtS CONTRAGT. {
��_� f
A: NVMBER OF +r ,/�� + 1 y "/ ,y ., -
PAYMENTS FOR THE , B. AMOUNT OF EACH PAYMENT IS ��� J y TaTAL OF PAYMENTS FOA'THE INITIAL TERM 1S � �v� I
p_ (NITqL TERM IS 36. (�'OTA O LY SERVICE CHARGE FROM BELOUVh � T�MES 8:) (E7CCLUSIVE OF ANY APPLICABLE TI1XE5, FEES, flNES I
� c i >' ' . . �- _ _ aND RATE INQtEASE53 �
LAIE G� -I E TO MY SELECTED BILLING ' -�-- �
�; ����� Qp�1� ��E�Q �{ E�S�ANT Of SERVICE. MY FlRST BIWCHARGE WILL i PREPAYMENT - IF I PREPAY THE � SEE SEC71pN5 2, 7, 45 RND �
Sl�I�Itf�qoE s YWk7k'R Y VICE BEG1N5. ADT MAY IMPOSE A TOTAL OF PAYMEWrS PRIOR 70 19 OF THIS CONTRACT FOR I
GE ON EA ENT THAT !S MORE THAN TEN (10j THE END OF THE INlT1AL TERM I ADPRIONAt INFORMATIpN �
�C-�`� ���� 7HE MAX AMOUNT PERMITfED BY WW, BIIf IN pp aR REF ND. ERE 75 Ho ANO C���ON DEFAUL7 I
NO EVENT YYILL 7H[S AMOUNTfXCE 65.00. i
,
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