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CITY OF ZEPHYRHILLS � �
5335-8TH STREET 13783
(813)780-0020
ANNUAL FIRE PROTECTION MAINTENANCE
Permit Number: 13783 Address: 38010 MEDICAL CENTER AVE
Permit Type: FIRE PROTECTION MAINTENANC ZEPHYRHILLS, FL.
Class of Work: FIRE-PROTECTION MAINTENAN E Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est.Value: Parcel Number: 35-25-21-0070-00000-0010
Improv. Cost: 25.00
Date Issued: 1/18/2013 Name: C G M HOLDINGS TRUST
Total Fees: 25.00 Address: 38023 MEDICAL CENTER AVE
Amount Paid: 25.00 ZEPHYRHILLS, FL. 33540
Date Paid: 1/18/2013 Phone: (727)484-1142
Work Desc: FPM-ANNUAL - FIRE ALARM- FL CANCER SPECIALIST
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Chapter 633, Florida Statutes,authorizes the City to charge and collect user fees to pay for the costs of fire
prevention and protection related activities such as inspections, plan review,administrative fees,and other
costs related to the aforementioned.
Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of
the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final
inspection shall be charged double permit fee per day of operation or a minimum of$100.00, whichever is greater. All
work shall be performed in accordance with City Codes and Ordinances.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMNT 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 �RECO IN Y R NOTICE
OF COMMENCEMENT.
PERMIT OFFICER
PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT- 813-780-0041
�ozo t;ity ot�epnyrrnus rire
rax-o i o-i ov-w��
Permit Application
Phone Contact for Permit �o��7 `1�a �'��
Date Received . 4. �:�.�.-r:,�..,=*,:.,�.�w..«.,,-�._�._ -
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Owner's Name d A � Ce
� C�.C�c�.���S� Owner's Phone Number , gI�J 7 S 3 � b1�
y37\ Veco���-0.S�SElo�o.�ec- ''(..5\Vd• ��: ers r-- 339 Ilc
o�,ars Aadress �� � �
Titleholder Phone Number
Fee Simple Titleholder Name
Fee Simple Titleholder Address - __ ��,_�. -
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, �„�,��i?�, _..... '�i�'"?�_'�' "�",�°°x'''�`r". - ��
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Job Address
38 O 1 O N� �c�\ C� '�e�- venue ��'#
Parcel#
Sub Division - - '�
,_�. _. ��m
II�Je:ar�x:�_..:: � :. . . _ . . . _ . . � - �
� Bio-Hazard Waste Storage-ANNUAL Fumigation Tent
� Comm Exhaust Kitchen Hood/Duct � Hazardous Material(Tier II or RQ Faciliry)ANNUAL
� Controlled Bum � Hood Instal�ation
aEmergency Generator<30 kw a LP/Natural Gas-Installation
� Emergency Generetor>30 kw � LPlNatural Gas-ANNUAL Sale
� Fire Protection Maintenance-ANNUAL � Places of Assembly-ANNUAL ���
LI�LrI"y� emi � er ❑
Sprinkler � ❑ ❑ O Recreational Bum •
Fire Alarm � 0 ❑ � � � Sparklers
Hood Cleaning � ❑ ❑ O � � Sprinkier System�nstallations �
Hood Suppression � ❑ ❑ ❑ � � Standpipes(Sprinkler Sys) �
a Torch Roofing/Tar Kettle �I �
� Fire Alarm Installation a
� Fire Pumps Waste Tire Storage ANNUAL
� Fire Works
� Flammable Application-ANNUAL Valuation of Project
aFuel Tanks
� Other: �
ln,,:{� ,. . . �#�. , . . . � '� ,
Contractor Company Q�re �'m `n
Registered N Fee Curcent Y/N
Signature
Address , \'3'�11c L License#
ELECTRICIAN Company
Signature Registered Y/N Fee Current Y/N
License#
Address
PLUMBER Company
Registered Y/N Fee Current Y/N "
Signature
License#
Address
MECHANICAL Company
Registered Y/N Fee Current Y/N
Signature
License#
Address
OTHER Company
Signature Registered Y/N Fee Current Y/N
License#
Address , ., � ... .
s � ,. .,.
Directions:
Fill out application completely.
Owner&Contrector sign back of application,notarized(Or,copy of signed contract with owner)
If over$2500,a Notice of Commencement is required(Mechanicai work over$5000)
Supply iwo(2)sets of drawings with applicable documentation
Allow 10-14 days for review after submittal date. Parcel#-obtained from Property Tax Notice(http://appraiser.pascogov.com)
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to "deed" res.,��cion�.'
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 viofation
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.
CONSTRUCTION LIEN LAW(Chapter 713, Florida Statutes, as amended): tf 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 "owne�', 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 apermit and that all work wiil be pe�orinecJ 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.
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 viotate, cancel, alter, or
set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building O�cial 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 IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTI OF COMM EMENT.
FLORIDA JURAT(F.S. 117.03)
OWNER OR AGENT CONTRACTOR '
Subscribed and sworn to(or affirmed)before me this �^ �
b Subscribed and swo to(or affi , fore me this
Who is/are persona0y known to me or haslhave roduced b�
p Who is/are per$ehally kno to me or has/have produced
as identlficatlon.
as ident�cation.
Notary Public Notary Public
Commission No. Commission No.
Name of Notary typed,printed or stamped Name of Nota
ry typed,prtnted or stamped
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