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a <br /> PERMIT APPLICATION <br /> UTILITIES LOCATE CONFIRMATION NUMBER: <br /> PROVIDE SKETCH IN THIS AREA, IF ADDITIONAL SPACE IS REQUIRED, ATTACH TO THIS <br /> APPLICATION: <br /> s 6 16 1 gbh S-trect <br /> 5o►co �$�, sf,e�.f <br /> a <br /> I( <br /> f <br /> g fh S +-t-e—t <br /> AFFIDAVIT: Application is hereby made to obtain a permit to do work and installations as indicated. I certify that all foregoing <br /> information is accurate and that all work will comply with all applicable codes. I understand these codes shall take precedence over all <br /> approved construction documents,and issuance of this permit is verification that I will notify the property owner of Florida Lien Law <br /> req.,F.S.713. <br /> The issuance of this permit does not ensure compliance with deed restrictions and I understand that additional deed <br /> restrictions may apply to this property. <br /> All work shall comply with the current Florida Building Code, Public Works Design Manual and FDOT Design <br /> Standards(if applicable). (Public Works Design Manual online link:www.ci.zephyrhills.fl.us/public works.asp) <br /> APPLICATION IS VOID UNLESS SIGNED WITH PROPER IDENTIFICATION AND WITNESSED BY A PERMIT <br /> TECHNICIAN OR NOTARY PUBLIC. <br /> NOTE: The City of Zephyrhills is not responsible for maintenance or repairs of driveways. Driveways shall not alter/ <br /> interfere with existing stormwater treatment and/or conveyance. <br /> PROPERTY OWNERS: By signing this application: I certify that I have read and understand the owner/builder disclosure <br /> statement. (please initial) <br /> Applicant Print Name A plican Signature Date p, <br /> Permit Technician Signature (or)Notary Sig ure*aitz> - h,5 Date <br /> Applicant isA.personally known to me or produced as identification. ,�`��@l�•M.9X <br /> (type of identification) �.�`�i`�`�0'fARy`ti/;P'", <br /> 2 des� i <br /> Page 2 of 3 My�Omm iq,202� a <br /> Se s 133466 <br />