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<br />l\., 110'1'1 cm Oil' nmJl~n HEB'l'llIC'I'IONS
<br />'J'lte 11l1ders.lgned IInderstands that: t.nJs pe,nnl ~ lll:\~' be ,;J'lb.le:u\: to "deed rElsl:dcltlons" Hhlch
<br />Way be 1II01:e resl:rJct:ive than CJty u=g1l1:;l:ioils. 'J'he 1~ldl=I::Jlql1ed aSSllwes respolls1.h.llJty Eor.
<br />comp.l lance Hi t.h any applicable deed r:es\:rJcl:lo,!loi.
<br />B. IlHI,ICHlHSE:l1 CON'l'HAC'l'OHB AND COI'I'1'Hl\(~'I\IH Ri'!lSPUII,S IBIT, L'I.'I H:.'J
<br />If the O\JJlet: has hIr.ed a cOlltr.aotor OJ: ':ont,[act:OI.B to lllldertake Hnrk, I~hey may be r.eqll:l red
<br />I to be licensed JII auuordallce vdth stat:e and loci,l J:egII.LutIolls. If t.he contractor 1s nol:
<br />Jluensed as re(pIJx.ed by lall, both Lhe OJ.mex.' and contu:\utor Jnay be o.l.ted for a 11\1 Ildemeanor
<br />v.!ulal:.!on 1I11dtill' state laH. If the OHne.t or .i.1l1~elJd.:d cOlltl'actor ate \1Ilr::ertal n as to Ilhat:
<br />I juensJn\] reljld.tE:lllents lIIay applyfo\: tlll:: intended \/Or.k" tlley are advised to (Jonl:ac\: the
<br />1:1 Ly oJ: Zephyrld 11s Bulldlng Department.. fl13-'/BB'''6611.
<br />J!'1I1Lllsrm<n:e, if the OWler has hl.J;ed a contracto); OJ: contractors, he Js advlsed to have t.he
<br />(JOlltrac;toL (a) sign portJons of l:he "Conl:rac!:or Sect:iolJs" of thJs application tor \/111011 they
<br />\/111 be respol1s:lble, If you, as the miner s.lglls as I:he contractor, you are Jnd:lnaU.ng thar,
<br />YOII, rather than the contractor', ar.e r.esponsible for the Hork. If the contranl:or. \-Ilshes
<br />YOII 1:0 a.l gl1 as aontr:actoJ: that may be all indicatJon that he is not properly L1 censed and is
<br />\lot entItled l:o penlllttillg pl:ivileges in the C:l.ty of :?,ephydlills.
<br />c. 'l'R1IN3PUH']'A'J'[O)'J IMPAC'l'IfEHISAIlD U'l'ILITY CONHEC'I'ION H'E1ElS
<br />D. COHS'l'RIIC'{'IIJON ],TE:H IJAW (CIIAP'I'ER '713, Fr,oRIDA S'I'A'l'lJ'l'ES, AS At1ENlHGD)
<br />I ce1:t:l fy tha\: I, the appLicant, have bean llrovided H.1 th a oopy of "I!'lor:l.da's Constt'lIctlon
<br />.1 j;;1I ],al/ .,. 1I0llleO\"ll)l:llr'S Protection Gulde" prepared by the E'.lorida Department: of AgriouJ.hlre
<br />and COII/3\lIl1er: Al'falrs. If the app.lJcant is someone other Lhat. the "aHner/I, I caLlfy that I
<br />have ol>taJned a oopy of the above desor.lbed dOCllrnellt and promise ill good :faJ.th to del.iver
<br />it" to the "()\'lI1er" prior to COlllJnellCelHelll~.
<br />H:, CON'I'HJ\C'I'On' S!OWNffifl' B l\FE'IDAVl'I'
<br />1 nel:t:.tfy Lhal: all tlte infolmaUon in thls appl..lcatlon .Is accurate and t.hal: all lIOr!, 111.11
<br />be dotJe 1n comp:l Jance \/JLh all applJcable .lavlS reg\l.1.atJlIg constntr:tiul1, zonlng, alld lalld
<br />de.vel.opmelll: ,
<br />ApplJeat.lnll :Is hereby made to obta:ln a perm1t to do work and lnstal.1.atlon as JllclLoated. I
<br />cerU fV that no ~lOrk or installation has oonunended prJot to issllallce ()f a pennU' alld that
<br />a1.1 Hark \./11.1. be performed to lIIeet standards of all 1a\..,s regulating (jOnsl:ruCltJon, City
<br />codes, zon.lng reg\llal:.t.olls, and .land development regu.lat.lons JII the Jur.lseUctJon, "[ also
<br />ce.tl: {fy Lllal: 'r lHl<lerst:and that the 1:egulat.lons of other govenllllenl:al agennJes may apply to
<br />tile .lnl:endad viOl:!;:, and thaI: .It 1s my .t:espons1bility to Jdentify l'lhal: autJolls I must: l:aJ(s 1:0
<br />be in compLlallce, Such agenctes .include bllt are not .Umlted to: *neparl:menl: of
<br />F.:llvJnJlJm8nl:al Hegulatioll'-Cypress Bayheads, Wetland Areaf.l and n:nvironment.ally SensU...tva
<br />Lands, Wa Let'/Was tel'la Lar 'J'rea LllIen!:
<br />"'Soutln/sat: J!'},od.da ~'1ater Nanagemeut Oistr.1 ct-Wells, CYPli'ess Bayheads, Wetland 1\1:6as,
<br />AJt:ed,ng Wal:eruo\ll::ses
<br />."II:III'{ CULpa of E:nglueer:s-BeaHal.1.s, Dooks, Nav.lgable Wate.rNays
<br />f'IJepa!:tmenL of Ileal t:h 6< RehabUJ tat:.t,ve Senr.ices, H:nvirOlllUenl:al Health lJuJt'-W611s,
<br />WaateHatet 'l'1:ea\:1I\6nl:, Baptle 'l'anl~s
<br />*11. S. ElnvJ l.olllnental Protection Agency-Asbestos abatemelll:
<br />1 also cetl:,l fy that, .It fl.11 material :Ls to be used In E'lood Zone "AU or "l\,el:c.", it .113
<br />understood that a drai.nage plan add1:essing a "compensating Volllloe" \-11.11 be submitted Illd.ch
<br />.is p1:epated hy a professional eng.l.neet reglstered in tile Sl:ate of I!'lor:lda pdor to perm!.t
<br />isslIallce,
<br />I\. permJ t .1 Bl::llled shall be <Jonst.rued to be a li.ceuse to pl:oceed Hith the Hork \!Iud not as
<br />aul:llDrl t.y to vJolat:e, cancel., alter, or set: aside any pro.vlsions of the l:eolmlcal codes,
<br />nor shall i SSlIance of a permj l: prevent the Bu.Ll.cUng OfflciaJ. from LhersElfte.r 1'e'1\l11:.1.ng a
<br />cou:euU 011 of errors in pl.ans, const.tllotJon, or violations of any aode. Everv perrnlt
<br />iasued shall beoome illvalJd unless the work autho);iz$d by such permit. 1.s nOll1lllenced \..,.Hhi n
<br />sjl( l1lonths of .1.sslIance, or :If \",ol:k authod.zect by Lhe perm.l.t 113 s\lspended or abandoned rot: a
<br />per.:lod uf sh, months after the U.me the Hork 113 commenced. One 90 day extenslOll of t.lme
<br />l1Iay be allO\leJ for. the permlt \'1.lth fee ohal:ge of $15.00. 'l'he eHtens.tOIl shall be r.equest:ed
<br />In Hrit:illg La the Buildlng Official. ,An approved inspection IIlllst be logged dlldng eflcll all(
<br />1I1011t:1l pedod, en the project \-1111 he considered abandoned.
<br />WARIHIIG '1'0 OWNmHl YUUR \i'AILUHffi '1'0 HI'~CORD A NO'l'TC!!', OF C()Mt1I!:NCI!1ME:r~'I' MAY nlr.SllJ.'l' JII YOUR
<br />PAYUIG TWICE !fon H1L>ROVEHEN'I'S '1'0 YOUR PROPER'l'Y. IE' YOU IH'l'E',11D '1'0 OB'l'JI.ItI F.'THAIICUIl3, COI/FJllliI'
<br />WITH YOllH I,l!:tWElR on AN A/l"l'ORHF~Y BEffOR!!', RECORDING YOllR NUTICE OF COI'1l'1E:NCF,t1EH'I'. ,lOBS lJH/lFr.R
<br />$2,500 III VALliE DO NO'l' HE:En '1'0 RECOil!) AND P08'}' A "NO'I'Iel!; OF COHNlmICEMH:tl'l'".
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<br />I,_,~.rr) }J .'.. '.I,"}~ (J.~! 8 iJ:: :-? ~~:<}~ '!~ '~f' A;: PI'],: DA v J rJ.'
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<br />SlGWI.'l'UHH: I UWHHlR lIB AGENT
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<br />.- .. - ---~ ~.- -. -.----...---. -, ----.~._~.,._. -"--'-'-"~''''-'
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<br />-......_~--_..-._..~_...~------...~-~ ------.._-. "--~-..
<br />
<br />SIGNA'l'lJRE:: CUN'l'R7\.C'l'On
<br />
<br />STN]'Hl UIi' 1!'],Ofnlll\
<br />
<br />COlJII'l'Y OE' ___.'__...__....___.________________._,..,
<br />
<br />'}'he foregoJlIg instrllment Has ackllo~/ledged
<br />Befol:e llIe tiLl s _.___._._ day of"._,__.____,_' l.!t__
<br />
<br />by _. _._._____ h, __. _. . _._..'___._.._._..___________._,_____._,_._____,_
<br />lnflme of person aolmowledged)
<br />[] \-Iho is pe.rsonally kIlO\-lrl to rue, or
<br />
<br />fl'rA'I'H: 0 F FLORI DA
<br />
<br />C 01 IN 'I' Y 0 E~ _____.__ _ ________,____ _._____.__..__._____..____
<br />
<br />The fOLegolng l11sl:rl\lllelll: \'laB aclwovlledged
<br />86fo1:e me tld.s _____Jiay of-------..---.__, 19
<br />
<br />by _.____'_'_______________._,..______ _~_._.__..__......,
<br />(name of person acknoHledged)
<br />Chllo .113 personal.1 y Imo\'1n to lIIe, Dr
<br />
<br />[I who has pl:odllcecl_______________._____
<br />(type of .identJfJcatLon)
<br />and wllo[1dJd f]c1td not t.ake an oath.
<br />
<br />[] Vlho has prod\\Ct;ld_.________________.____.._.
<br />(type of Idel1l:1fJeodlon)
<br />and ~lI\O [Jdld []Ud not l:alte an oath
<br />
<br />.-...... -----.-.--.-- -----______.___.h ._.__._.~___._._._._.___
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<br />.-...~--.._-----_._-~._.__._._----_._, ..-.---.--.-- --- .------------
<br />
<br />El.1 gl1a\:lIre of persoll tak.ing ackno\'lledgelllent
<br />
<br />SLgllal:nr:e of person takLng ac:ltIJ01/ledgment j
<br />
<br />Nallle typed, pd nLed 01: stamped
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<br />-............ -_.-.--."._..~ -" .-.- ..- -,~ .-..---.-----..~---. ".-... .'-' ',-..-~-_-___~~.___..r.,_,.__ _._
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<br />'~-.---.,-----,,- .----.----------.--- h' .__.._._.__~_.,.._____.~__.. "0__'__.__ .._______.__ __,_.
<br />
<br />Name typed, prJ,lIted or sl:amped
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