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� �. <br /> 1 PERMTi APPLICATXON <br /> h <br /> I l`f�'iYnf�'iR9i'las�� � <br /> UnLtRES LOCATE CONFIR�lA'RON NUMBER: � �,y� � <br /> I�R171/IDE SKETCH IN THIS AREA, IF ADDITIONAL SPACE IS REQtJI�RED,ATTACH TO THIS � � � � <br /> APPLxCATIQN. '= � � <br /> 4 � <br /> �.� � � -��p�� f � 3 N � <br /> •�J�i�,, �Ac��, ��► ,r�j <br /> �,���, � � �' �� � 3 � <br /> �a ��� � � <br /> 4 d <br /> � � �.e....�....___ � ,.�-�''— 4� -+— �" '�� ��,.� 1 <br /> � ~�'� ` �C � _ �� ..a,.`�,Jr. ,.�. <br /> - -^w---....`.__�.�, r---.,. '�' \` C+� i�_ _/ <br /> �, �- ,�' ` � ��\ S� �'�y� �� �'� . <br /> , � <br /> � —� <br /> '� '�' t'r '�.,,. `� '°��, „� �: ��y-� <br /> o � � . <br /> � � �. <br /> � `-_� y`�� � /'�'�� +',M �'� "" I� <br /> �_ � � <br /> � � _ .f` � �� 1f (� � � <br /> ___ - -� - -- ._.___T__—. � i� � �� � �I <br /> �:1',��'��� �3 .� �` <br /> �R� ` <br /> � ��*`-�� � 5� Q�k��,I? � <br /> � <br /> AFFIDAVIT: App(#caficsn is hereby made to obtain a permit to do work and instailations as Indicated. I oe�tify that ali fonegoing <br /> lnformatlon Is accusate and t�tat ap uuadc wil!a�mply wittt aq apptEcabte cades. i understand these cndes sha11 take preredence ov�r aii <br /> approved o�structfon dacuments,,and issuance a�f th(s permlt ts veriticadcan that I w!!I notify tt►e pmperty owner of Fbrida Uen Law <br /> req,,F.S.713. <br /> The lssuance of this permit does not ensure cnmpliance with deed re.strfckions and I understa�d that additiona!deed <br /> restrictions rr�ay appty ta this properly. <br /> Ail wrork sfiail compty with the cument Fiorida Buttdln�C�de,PublTc Works Design Nlanual and FDOT Des➢gn <br /> StandaMs ttP appliCable). (Pablic Works C7esign Ntanuat anline fink;www,ci.xephyrhNts.fl.us/pubtk_works.asp) <br /> APPLiCATION iS VOID UNLESS SIGNED 1NITH PitUPER IDENTIFICATION AND WiT1VESSED 8Y A PERMIT <br /> 7EC�iNIt�4N�R NOTARY PUBLIC, <br /> NOTE: 'i'he City o}2epfiyrhills ts not rcspansfWe!arc mainten8noe or repairs of driveways. Driveways shall nat alter/ <br /> interfene with exiating atormwaber#re�bnent and J or aanv+�ayance. <br /> PROPERTY C3W ER�: 8y SlgNng thts applic�tlon: I .r�rtify that I have rea��and underskand the owner/builder disclasure <br /> sbt_ment �•d�'' (ptease in1t1a1) / <br /> � r�L�•� G�p_ vl�d � { d` <br /> Appllcant Print�latne Ap�lica t St ture ti Date <br /> Fet'tNtNt Techntdan Slgnat�re (flr)Nabry S(gnature Dat+e <br /> ApppcaM is( )persoaaliy Imown to me ar produced as identiflcatlon. <br /> �tYPe of trlentiFicatiart) <br /> Page 2 of 3 <br />