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Home My WebLink About13-14105 CITY OF ZEPHYRHILLS /,. 5335—8TN STREET , ` (813)780-0020 '�'� FENCE PERMIT Permit Number: 14105 Address: 7210 OMEGA CT Permit Type: FENCE ZEPHYRHILLS, FL. Class of Work: FENCE/NEW Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: ALPHA VILLAGE Est. Value: Parcel Number: 35-25-21-0050-00000-0740 Improv. Cost: 1,040.00 Date Issued: 4/19/2013 Name: BRUNSON, KATHLEEN(JOANN STEEN) Total Fees: 45.00 Address: 7210 OMEGA CT Amount Paid: 45.00 ZEPHYRHILLS FL 33540 Date Paid: 4/19/2013 Phone: (813)355-4557 Work Desc: INSTALLATION 175 X 6 STOCKADE FENCE OWNER FENCE 45.00 �� c.�.e�� v� �,� �-�c�, _ o� ha�o ��n �y�1 � � . �� / ' � 4 / �'-��i ►� �- " �� -9 /� ' � y �� {�l v c �� 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 inspections 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. The payment of inspection fees shall be made before any further permits will be issued to the person owning same Complete Plans, Specifications and Fee Must Accompany Application. All work shall be pertormed in accordance with Ci Codes and Ordinances CONTRACTOR PERMIT OFFI ` PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER CITY OF / / / / BUILDIN� ZEPHYRMILLS DEPARTMENT OF ADDITION OR CORRECTION � • • - • ADDRE55 DATE PERMIT�, �. � � � `��-� C T � J�7 / THIS JOB HAS NOT BEEN COMPLETED. The following additions or corrections shal) be made before tha job will be accepted. G�(� .SI G p P C��'//t'C � ! . � J" �r�,� C f� /-� , � C1 . � �t is unlawFul tor any Carpenter,Contractor,Builder,or other persons,to AFTER CORRECTIONS ARE MADE CALL cover or cause to be covered,any part of the work with flooring,lath,earth 780-0020 FOR -IN .E ��N or other material,until the proper inspector has had ample time to approve L � the installalion. /� OFFICE HOURS 7:30 AM-5 PM MON-FRI INSPECTOR CITY OF / / / / BUILDINt1 2EPHYRWILLS DEPARTMENT OF ADDITION OR CORRECTION � • • - • ADDRE55 DATE PERMIT�, �n �- ✓� C� �" �''.Z�i3 j�i � cs� THIS JOB HAS NOT BEEN COMPLETED. T e following additions or corr ctions shall be made before tha iob will be accepted. 6�� t r��-� � �..� �v�2 n.l�� i'9-�c� v�� r,.��. s i 1 r c�v,,r— It is u�lawful tor any Carpenter,Contractor,Builder,or other persons,to AFTER CORRECTIONS ARE MADE CALL cover or cause to be covered,any part of the work with flooring,lath,earth 780-002 FOR RE-INSPECTION or other material,until the proper inspector has had ample time to approve the installation. OFFICE HOURS 7.30AM-4.30 PM MON-FRI INSPECTO . 813-780-002C City of Zephyrhills Permit Application Fax-813-780-0021 Building Department Date Received Phone Contact for ermittin _. � � � ��.-3:3`5:�- .��s- Owner's Name ,P_ ll'(,(_ i Owner Phone Number �Owner's Address � v � Owner Phone Number � Fee Simple Titleholder Name Owner Phone Number � Fee Simple Titleholder Address �JOB ADDRESS � e � LOT# �� SUBDIVISION PARCEL ID# (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED � NSTALLST�e REPAIR LJ SIGN � Q DEMOLISH I�1 PROPOSED USE � SFR Q COMM � OTHER TYPE OF CONSTRUCTION Q BLOCK Q FRAME � STEEL Q �DESCRIPTION OF WORK � C '� j BUILDING SIZE � � Sq FOOTAGE�� HEIGHT �UILDING $ � VALUATION OF TOTAL CONSTRUCTION DELECTRICAL $ AMP SERVICE Q PROGRESS ENERGY Q W.R.E.C. OPLUMBING $ ��(�. QMECHANICAL $ VALUATION OF MECHANICAL INSTALLATION � OGAS 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 SiGNATURE REGISTERED Y/ N FEE CURRE� Y!N Address License# PLUMBER COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N Address License# �— MECHANICAL COMPANY SIGNATURE REGISTERED Y I 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 FoRns;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 Fadlitles 8 1 dumpster;Site Work Permit for subdivfsionsAarge projects COMMERCIAL Attach(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 wJ Silt Fence installed, Sanitary Facilities 8�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 construcUon. Directions: Fill out appiication completely. Owner&Contractor sign back of application,notarized If over;2500,a Notice of Commencement is required. (AIC upgrades over ST500) `" 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 restrictive than County regulations. The undersigned assumes responsibility for compiiance 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 Transpo�tation 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 "ce�tificate 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 certiy 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 & 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 Iots tess 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 pe�mit 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 justi�able 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, CONSUL7 WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. FLORtDA JURAT(F.S 7.03) ,�_ OWNER OR AGENT {/fl_ CONTRACTO� � - Subs bed and s m (o .atflrme )before me Subscrib�nd (or afflrmed)be re e is —�3 by ' y Who isJare perso y known to me or as/have produced Who Is/are pers ally novm to me or has/have produced �'� '�-��,,Q,;(�� as fdentlfica8on. �L �►"� -+ e•-- as identification. � , ry Public � Notary Public LT c� � ' , � _,: :;: comm�s�o�►#E oao52o co `� ' ion#E�040620 co m on - • •, , �g , ••�;p;,y,•• eo�aearn�,rroyFamtr��eoo-3esao�s 901id�d 11YU Tid/Fdn Yrueros A00�3B�7019 Na , Name of Notary typed,Printed or stamped � DISCLOSURE S'�'A'f'F'*�'NT .FOR OW1�R CZTY OF ZEPHYRHII+I+S BIIII+DING DEPARTt�NT _� ' have read and fu1Zy understand and agree •to the provisions of �t�is instrume�t. The undersigned .sta.tes and affirms that he or she is desirous of constructing, renovating, adding to or seroofing his or her own domicile, •that he or she actually occupies, or will occupy by said domici:le, asd same is not for •rent, lease or sa1e. That he or she shall comply with the following conditions: 1. That the ovmer and�he or she alone sha11 act as the bvilder for a11 phases of construction. 2. That the owner w3:11 comply with all provisions of �the City of Zephyrhills ordinances and codes pertinent to the build.ixig. 3. That in the event various phases o£ construction are subcontzacted, he will engage only properly licensed subcontsactors and will personally supervise such work. 4. That in the event the Huilding "Inspector sha11 rec�"re correctioas to be made, the owner wi11 assume full responsibility to insure •they are made, and upon completion wi11 call for a rein_�ction before proceeding with the building. 5. Tlzat the owner sha11 assume �fu11 responsibility for the consts�action and wi11 not axpect_ supervision of his work from the City .of Zephyrhills Building Dapari�ent. 6. That prior to final inspection any acidttional fees, including reiaspection fees, must be paid i.a full. A written request from this office sha11 constitute an official notice -to pay add:itional fees. _ 7. That the ownes sha11 co�ply with all City, State and Federal laws in regard to social security, warkman's compensation, liea 1aws, etc. , whese applicable. B. That the ownes shal.l comply with all the safety codes issued by the Florida Industrial Commi.ssion. 9. 5tate 1aw re�,;res constructz.on to be done by licensed contractors. You have applied for a permit under aa �cemption to that law. The exemption allows you, as the owner of your property, to act as your own contractor with certain restrictions ev� though you do not have a license. You must provide direct onsite supervision of the construction yovrself. You may build or improve a one-family or twc-family resideace or a fatm outbuilding. You may also build or improve a co��+�-cial building, providsd your costs do not e�ceed $25,000. The building or residence must be for your own use or occupancy. It may not be built or substanti.ally improved for sale or lease. If you se1:l or lease a bvildirsg you have built or substantially improved yourself vrithin 1 year aftES the construction is complete, the law wi11 pres�e .that you built or substantially improved •if for sale or lease, which is a violation of this exemption. You may not hire an unlicexised person to act as yovr contractor or to supesvise people �vorking on your building. It is your responsibility to make sure that people e�ployed by you ha.ve licenses rez+,;red by sta.te law and by county or mu=iicipal licesising ordinances. You may not delegate the responsibility for supervising wosk to a licensed contractor who is not licensed to perform the work being daaa. Any person workiag on your building who is not licensed must wark under yovr diract supervision and must be E$Ployed by you, which means that you must deduct F.=.C_A. and withholcling tax and provide workers' compensatioa for that employee, all as prescribed by law. Your construction must comply with a11 applicable laws, ordisiances, building codes, and zoning r a 'ons. �R'S S2GNATL7RE �AR.'E � �,,,�_ O�ADDRESS ��PHONE W2TNESS PERL�T # CITY OF ZEPHYRHILLS BUILDING DEPARTMENT Owner: Job Location/Address: Parcel I.D. #: SHOW ALL EXISTING&PROPOSED STRUCTURES GIVING DIMENSIONS&SETBACKS UTILITY BUILDINGS MUST SHOW SIZE & FOUNDATION INFORMATION I � � � r � � _ I � 1 � � �' 0 ,- _ � _ _ __- i °� ,��. - - - STREET - - - - - - - - - - - (NOTE EXAMPLES 1&2).. Example 1. Setbacks for R1 &R2 Zoning Example 2. Setbacks for R3 Zoning � I 60' I I 6U �a io� P E R X 0 I 10, F�51'AlG 10' p S �a o T ia laa S I 1� E N D G PR4POS� �p� 20'•SINGI.E FM�.Y! �'DUPLIX FRONT PROPERTY LINE IRONT PHOPLRTY LiNE - - - SfREET - - - - - - - - - - - - -- SfREET -- - - - - - - - - - Map - Pasco County Property Appraiser Page 1 of 1 Pasco County, Florida Section 35, Township 25, Range 21, 2.0 miles N of Zephyrhills Mike Wells � � � Pasco Countv Procertv Anoraiser r�o When I click on the map: � Quick Info Full Info* o Zoom In 1.5x 7�0 . _ Choose La ers: �' 'K�''°'"LL�,° Y ' �� ,i- ' -- Parcel Lines(Default) - -- Parcel Labels(Automatic) -- Street Names(Automatic) 2011 1 ft-Color --Select Additlonal Layer --Select Grouping �� Image Size / Quality: o�000 (Quality applies if imagery is selected) �ao Low Quality(Fast/JPEG) Links of Interest: Recent Sales in this area ` ', J Search for pronertv in Pasco Man Search � � 113 Feet MapID#17993162/4222 Street name information is maintained by the Pasco County BOCC GIS Department. http://maps.pascogov.com/maps/showmap.asp?Name=P ascoMap_New&mdi=17993162&... 4/19/2013 Pasco Co�anty Parcel: 35-25-21-0050-00000-0740 001 Page 1 of 2 Data Current as Of: Weekly Archive - Saturday, April 13, 2013 Parcel ID 35-25-21-0050-00000-0740 (Card: 001 of 001) Classification O1 - Single Family Mailing Address Property Value BRUNSON KATHLEEN Ag Land $o 7210 OMEGA CT Land �i5,i25 ZEPHYRHILLS FL 33540-1416 Building $5i,z2� Physical Address Extra Features $998 7210 OMEGA CT ZEPHYRHILLS FL 33540-1416 7ust Value �78,350 ASS2SSed (Save Our Homes) ��s,350 Homestead 196.031 - �z5,000 Le4al Description (First a �ines) Non-School Additional Homestead _ $2s,000 See Plat for this Subdivision Exemption ALPHA VILLAGE ESTATES PHASE 1 Non-School Taxable Value ;2�,sso PB 19 PGS 69-70 LOT 74 School District Taxable Value #s2,sso OR 3078 PG 239 Warning: A significant taxable value increase may occur 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 1 0100 S�R OOR2 7,500.00 SF $2.15 1.00 $16,125 Additional Land Information Acres 0.17 Tax Area 30ZH FEMA �Residential Code ALFALPI Code Buildin4 Information - Use 01 - Single Family Residential (Card: 001 of 001) Year Built 1982 Stories 1.0 Enterior Wall i Concrete Block Stucco Exterior Wall 2 None Roof Structure Gable or Hip Roof Cover Asphalt or Composition Shingle Interior Wall 1 Drywall Interior Wall 2 None Flooring i Carpet Flooring 2 None Fuel Electric Heat Forced Air- Duded A/C Central Baths 2.0 Line Description Sq. Feet Repl. Cost New 1 BAS 1,446 $71,577 2 FGR 324 $6,435 3 FOP 80 $990 Extra Features (Card: 001 of 001) Line Description Year Units � Value � DWC 1982 350 $381 2 CON PTO 1989 �- 232 $313 3 UDU-M 1997 � 1 � $304 Sales History Previous Owner DECOSTE VIRGINIA A I—�f�f�'-1 http://appraiser.pascogov.com/search/parcel.aspx?sec=35&twn=25&rng=21&sbb=0050&b... 4/17/2013 L , � �� _—________�_,._.__—__—____—.__"_ _______..__._"—_____.��.._—'_"_"_"_�_..."_.__'_'_'___._"'_'. ' i It `I f 1 ' ' ' " ! ''' ' I 1 1 1 ' 1' I� � � �� OFFICE of VITAL STATISTICS � � - CERTIFICATION O�F DEATH - STATE FILE NUMBER: 2013049514 DATE ISSUED:April 9,2013 , DECEDENT INFORMATION STATE FILE DATE:April 9,2013 NAME. i(ATHIEEN BRUNSON - , DATE OF DEATH: April 5,2013 SEX. FEMALE SSN: 297-20-6877 , AGE: 087 YEARS DATE OF BIRTH: September 6,1925 BIRTHPLACE. UNKNOWN PIACE OF DEATH:HOSPICE � FACILITY NAME OR STREET ADDRESS.GULFSIDE CENTER FOR HOSPICE CARE � IOCATION OF DEATH:ZEPHYRHILLS,PASCO COUNTY SURVIVING SPOUSE,DECEDENT'S RESIDENCE AND HISTORY INFORMATION - MARITAL STATUS: WIDOWED SPOUSE:NONE I RESIDENCE.7270 QMEGA COURT,ZEPHYRHILLS,FLORIDA 33540,UNITED STATES COUNTY�pASCO i OCCUPATION,INDUSTRY� HOMEMAKER,OWN HOME �CE. XVuhita BlackaAiricanAmerican Asienlndian _C�uiese _Ftlipx�o NativeHawaiian _Japanese _KOrean Amersan InEian w Alaakan Nelive—Tribe� Yetnamese Other Aaien �Guamian w Chamorro _Samaan _Other Pecific Icl: �Ottwr , _Unknown ' HISPANIC OR HAITIAN ORIGINI NO,NOT OF HISPANIC/HAITIAN ORIGIN ED'UCATION:HIGH SCHOOL GRADUATE OR GED EVER IN U.S.ARMED FORCES?NQ; I PARENTS/►ND INFORMANT INFORMATION � FATHER: UNKNOWN UNKNOWN MOTHER: UNKNOWN UNKNOWN INFORMANT�OANN STEEN RELATIONSHIP TO DECEDENT EXECUTOR INFORMANTS ADDRESS:49d03 LINCOLN AVE,ZEPHYRHILLS,FLORIDA 33542,UNITED STATES , � - PLACE OF DISPOSITION AND FUNERAL FACILITY INFOI�MATION � PLACE OF DISPOSITION:CREMATION CENTER DADE CITY,FLORIDA METHOD OF DISPOSITION:CREMATION FUNERAL DIRECTOR/IICENSE NUMBER: LINDSEY A.PALMER, F042218 � FUNERAL FACIUTY� HODGES FAMILY FUNERAL NOME-ZEPHYRHILLS F040699 , 36327 US HWY 54 WEST,ZEPHYRHILLS,FLORIDA 33541 � CERTIFIER INFORMATION TYPE OF CERTIFIER:CERTIFYING PHYSICIAN MEDICAI EXAMINER CASE NUMBER: NOT APPLICABLE TIME OF DEATH(24 hr): 0028 CERTIFIER'S NAME. SUJANI AKKINENI CERTIFIER'S LICENSE NUMBER: ME107752 , � NAME OF ATTENDING PMYSICIAN(If other than Certifier): NOT APPLICABLE CAUSE OF DEATH AND INJURY INFORMATION ' PROBABLE MANNEl7 OF DEATH: NATURAL CAUSE OF DEATH-PART I- and Approximate Interval: Onset to Death: � a END STAGE COPD " b FAlLURE TO THRIVE , c ' I .,. d PART II-Other signiTicant conditions contributing to death but not resulting in the underlying cause given in PART I: ATRIAL FIBRILLATION I AUTOPSY PERFORMED?NO AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH7 DATE OF SURGERY• DID TOBACCO USE CONTRIBUTE TO DEATH?UNKNOWN REASON FOR SURGERY� IF FEMALE,WAS SHE PREGNANT WITHIN THE PAST YEAR�NO NOT PREGNANT WITHIN PAST YEAR - DATE OF�iNJURY� NOT APPLICABLE TIME OF INJURY(24 hr)', �NJURY AT WORK? LQCATION OF INJURY' � , DESCRIBE HOW INJURY OCCURRED - i � PLACE OF INJURY• `} IF TRANSPORTATION INJURY,Status of Decedent: Type of Vehicle: - �G�.�� .it --_ J,} ,SWteRegisVar REQ: 2073711767 ,. TME ABOVE SIGNATURE CEFTIFIES THAT THIS IS A TRUE AND CORRECT COPV OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE tNF,SrA THIS DOWMENT IS PRINTED OR PHOTOCOPIE�ON SECURITV PApER WITH WATERMARKS OF THE GPEAT �pF AF, WARNING: SEAL OF THE STATE OF FLORI�A DO NOT ACCEPT WITNOUT VERIFVING THE PRESENCE OF THE WATER- --'I Or. MARKS THE DOCl1MENT FACE CONTAINS A MULTICOLORED BACKGROUND,GOLD EMBOSSED SEAL,AND �� TMERMOCHROMICFLTHEBACKCONTAINSSPECIALlINESWITHTEXTTHISDOCUMENTWILLNOTPRO�UCE � . 'u A COLOR COPV 8 i ,•��OOOwetW�•�., IIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIII�I . DM F�M 1�7(11/17) � •., r�wunno�aern�.n�oF �` _ � S a � s � a ,. ,. �. _ HEALT � '��