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<br />CU)ILJJ'l'lONS Of' i'b;kl'1TT Af'FTDAVI'r
<br />A. NUl'] CIil 01" llE:ED HES'}'RI C:'J'] 011::>
<br />'I'll.. unde).::;igned Ilndt:::.l:stcll1ds thi:lt LJii:> po:ulli t lliay bo:
<br />lIIa y be more r:es tr 1 ctl Vb than C1 t y re\.lll1 0. t 1 ons . 'l'h",
<br />complicmce vd th any, applicOlDle d""cd rt::st.r:ict:ion:;.
<br />B. IlNl,ICl!ill.:il!;f) CCtH'l'RAC'l'ORS AND CON'I'kfl.C'l'uR Rb;Sl:'OHSIBlj,I'l'II!;S
<br />If the Ol/WH has hired 01 (lulllractor OJ: contractor:; to undertake \JC1rk, tIH::Y IlIOlY be )':\i;:quin::d
<br />Lo be liGe:nsed in accordance \Iltb slate and lOGal r<::yuli:lUOllS. If the: C(Jntri;lc(:Ol.. II;; lIot
<br />IlGE:;nsed a':; l:.;;quired I)y 1al'l, both the ()'IlH=r and contractor lIIay I,J"" c} Led f01' a llIisde:Jiil:::anol
<br />vjolatiun Wider ::lti;lte lenl. Tf th.:: ClImer or int;;;ndo;;;d contr:actor OIL;;; 11Ilct:::r.tdJn ",:; to 1~ItC:lL
<br />Ii censinlJ reglli rel1lE:;lIl.s l1li:lY apply :tor the intended work, they cat::: ddv1st:::d to conLi:lcl: th;;;
<br />City of Zt::pbydd lIs bui! dj lHJ D;;;partlllent., t:l13-'7 &8--6611.
<br />E'IU:t1I~LIllOLt::f if the o"mer haS Id,1.:t::d a contract.or or contract.or.::;, be it> advLH::d to Ili:lVe Lilt::
<br />contract-or: (::;) tlign patti ons of the "Contractor Sections" of this appli cation tor \IIJi cll t11t;;y
<br />will be responsible. If YOII, i;lS the owner ::;1gns as thE:; c6ntrautor, YOll are indJc~ting thQt
<br />'lOll, rather thC:ln the c011tr:actor, are responsilJle for: the wor:k. If Lhe c(Jntr<'lGtcJ!. ~JisIH:l1;;
<br />you to ::;i gn OIl;; eontnlctor that !nay D<:: an ind:lcCltion t1lat ht::: is not pr:oped,y :u c",n:;led and is
<br />lloL t::ntit.1t::d to penll:lLting privileg;;;l:; in the City of ~c:phyr:ldlls.
<br />C. 'I'RP.HSl'OR'I'A'J'J011 H1PAC'1' 1"Eh:S AND IJ'J'lLI'l'Y CONHEC'I'ION f'Eb;S
<br />n. CONS'l'RllC'l'llIOll LH;H LAW (CHAP'I'EH 713, FLORIDA S'I'A'!'U'I'ES, AS AI'1EN\lIW)
<br />I ct:::l:l:ify that I, the aiJPUednt, hi:lve been provided witll i:l copy of "[j'lorida'l;; COn:.ltulCtion
<br />lien Lel\l - 1J0HLeOWIi:::.l'S PLotaction Gldde" pr;;;pi:lr<::d by the floridOl J)epi:ll..t.wi:::nt of Agri cllltlu:=
<br />C:llld COnl::lllll1<::1.: Attail:s. It Lhe applicant is SOllldOlle other t.hat th<:l "o~m"n''', 1 (;erify that l'
<br />havt:: obti:lined a copy of tht;: abuve dt:scr'ibt:d dOCIllHt:nt and promise in good fa.l.t.1J l.o dt::Ilvcr:
<br />i L tu tht:: "o\lnf:::).:" IJl..'lor' to COllUllC:llCt::J1I;;;nt.
<br />E:. COW1'kAC'I'OH' a/OWNER'S At'FIDAVI'f
<br />1 ccrUry l:h"d: a.1.1 th", lnturmat.iun ill t:hi,:; applicQticJlj is accurate and t11i;lt a.11 H(H,], ~Ii.ll
<br />be dOH;;; ill cumpl.ii;lncl;; \JiLh all applicable: laHS r<:lgulating constnlCtion, :<;onlllg, i:md li:lfJd
<br />Jevt:::l.opHlo;;;llt,
<br />Application i.::; her:eby made to obtatn a p,Hmi.t to do \'lOrk and inst.al1i:lLlon as illdic~ted. I
<br />ce!:'U ty that Ilu vfOrk or installation Ili;lS commenced prior: to is;;;\lcHlCi::: of. C:l pt::nlli L i;lwl LIJOlt
<br />C:l1l \'lOllc ~~i.l1 b<:: performed tu mc:eL standards of all la\~s rt:gulating COfl::ltnlUl.1on, City
<br />code:>, zoni1l9 1.::g\l1 aLion,:;, dlld li:llld devt:::loplllent rt::gulations in tilt: juri :.ld.l.ct:Joll.1 dl/;:;o
<br />c<::r:t:ify that: J lUlderstand LbOlt the regllJ i:lUans of otber CjoveLrllnental agclH..:lt::s Hlay i:lP1J.l y to
<br />tile intended \r101.:k, cmd Lhi:lL it is my lesponsib1.1ity to identify \rlh<'lt acU ons I llHll:;t, ti:lke to
<br />be ill cowp liancc::. Such C:lgellcie.::; incl udcbllt i:lr'e not .1 imi ted to :^'De:paltllli::mt of
<br />l!;nvi.l,onllle:ntal kt;:g\JlatJon-~C'ipres.:i Baybeads, We:tland. Ar:ei:lS and l!;llvircmmenLod,ly Sl;llll;ii t.l.Vt:i
<br />Lauds, WC:ltf:::t/Waste~~ater 'l'n::<'llmt:nt
<br />"t)o'ltln/e::;t: Jj'lorlc.ja W",tl;:r Hclllag~H1el'lt lJit>trict-Wells, Cypress Baylle::Cids, Wt::t.land Area""
<br />Al tt:::rinlj v~at=rcolJ1.:so;;S
<br />^AnllY CUL'f'.:i uf HlngillcQl:::;-St:Cll/alls, Docks, NavJgable Wate::rHi;lY.:i
<br />"IJc:!-,arLllIent of Ue::cd,th & k.::llabilitat1,vo::: 5ervicE:;S, }.!;nv1.!.'onlllentC:ll Ut::altlJ lJlllt-'We:1J.:l,
<br />Wi:l.:lt:c.llater 'l'r:ei:lLIlIl;:llt, 5;;;pl:i,; 'l'anks
<br />kU. t;, li:nvi.l..omnenta.l Protect.ion Agt:llcy'-A::lbe",tos abate:rnent
<br />I al;;iu certify thOlt, if fill H1atl::r1al i.s to be used in l!'1ood Zone: "A" OJ, "A,l;:l:c.", .it.i..
<br />under::ltooJ Lllat a ciLaina(jl::: pIall addre::::i::;ing a "cuwpemsaling vollllne" vJiJl bt::: ",ublLli ttt:cl Hldclt
<br />is [JLt:paLed l)y a fJl'l:Jte.::;sJCinal engillet::1.: regi:::itt:h::d in the State of Jj'J oriLli:l pl:i 01 to l)bl:llli t
<br />is::lllanCt:: .
<br />A pe:rmit issued shall be conatJ::\le::d to bt;: a license to proceed vdt.:h the:: H(nk and not "''''
<br />autlJOd t'l to violQte, CCiIlC;;;l, a1 ter, or set: ",side any provisiono of tilt:: It:chn,icOIl Oudt:I;;,
<br />nor i:ihcdl i;:;sllaflce of a penlli t prevent tilt::: Building Off1.cial from then::dfter Leljiliring a
<br />correction of errors ill plans, construction, or violations of any code. ~very V~rmit
<br />is.:>ued .;;110111. become invi:l1id unless the Hork author'ized by slIeh permit is COllUHi:::llul;:d Ili tldn
<br />.::lix llIonlh::l of is.::llHmCe, Ol' if \'IOrk authorized by the: peLllliL is Sll::>p'::llded Ol od'andcmcd fi.H' i:l
<br />pt.ri od of si.. fllont!J::l afti:ll: the timr;: the ~1U.1.:k i.::; GOllUllcnCed. Dn<:: 90 day E:;"cL t:n:;i 011 ot U Iflt:::
<br />may be aJlo\Jed fur: thE:; permit llit'll fE:;t;: charge:: ot $15.()(J. 'l'h<:: t:::",tt::lj::lion shall 1Ji;: reqljt;:j:jt:ed
<br />i,n ~ni ting to the Blli Iding Official. An approved ilHipecti,on must be l09\Jt::d d1ll'illU ei:lCll sj l'
<br />Inontb period, or tilt::: pcoject Hill be con::>1.dered abandoned.
<br />WARHn~G 'J'() OWNER; 'iOlJl{ li'AlLURe: TO RECORD A NOTICE Ol!' COIYJl>1ENCElvjt!lN'f' HAY HJj;SUl:l' III '1'001{
<br />l?AYING 'l'WICE Ii'CJR n1PROVEJvlEtJ'1'S '1'0 YOUR i'ROPER'fY. I1f' YOU IN'fEND '1'0 OB'l'AIN li'INAHCJlW, CONSlIL'!'
<br />WnH YOUR LEIHJER OR AH AT'l'OHHEY BEI!'ORE RECORDING YOUR NO'I'ICE Of C01YJ]vjEHCI!;M}'!;I~'1'. ,10bS \IIfnEH
<br />$'>, 00 H' VAWE DO flO'" I ,En 'I'D ~Nll POST A "IW'r)CE 6'0 cOMMEfle.,."".," '_
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<br />\ ,~M SiGNA~"~~~-----
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<br />S'I'ATE Oli' I!'LORT[)}\ ~/} S'I'A'l'E OF IfLORlnA
<br />COUNTY OE' -- .--.-. -,,----- eO\II-I'l'Y Ol!' '_.__.__.__._____,__________._____.
<br />Tilt; to.l:egoing int>t.:rmnent: \/as acknoHledged The foregoing instnmlt:ll(: "~i::Il::I aclwovll edgCid
<br />before llIe this _._.___, day ot __~ , 19_ Before me thi.::; ___n__rl",y of---------,--, l~
<br />
<br />b y ..~ __________..___._ .____ _ ___________.___.___. b jl ____..._______~______.____..__."__.___~.~_..___..__________ ____.~__..
<br />(nClme of p~rson acknowl=dVt:d)
<br />rJlbo ia pt::n:lOna 11y known tu 100;;;, OJ::
<br />
<br />.:;ubj t:::ct to "deed .1.:t:8tric1:iolls" villi dJ
<br />'Hldersi.yned aI;;SIWlt;:;:> rel:>pon::li jli,lJty tor'
<br />
<br />
<br />(n~nt:: of perl::lon i:lcknowledged)
<br />o v/ho is pE:;rlilonaIly knol'w to file, or
<br />
<br />[J \~lJo lla::; produced______
<br />(type
<br />alld \'/llOr] did l'JdiJ nolo
<br />
<br />of identification)
<br />tal;e an uatll.
<br />
<br />1] \lito bas product:::d
<br />, TI~Yr~'-~-;[i:i'~-;~lui ri ca L1 I,dl)
<br />and \1110 ['1 d iJ [~Hd 11('[ 12! ke dll Oi:l III
<br />
<br />Si gnat\no;;; uf person taking acknovil,edgement
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<br />'_._---".._--------~._~------"_._-. ---.-.- - ~~._.._--~---_..~_..
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<br />Signature of p€Jrson ti;lldng ackuovl1 i::Jdgmc;nL
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<br />---.-..---.---...----,,----...--., --"-"'--.-'-
<br />li~-l~'I~U-typ-:~ pJ:i ntcd or :>tampcd
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<br />...------.-------.-- ---- - ~~.- --_.-;...._....~-_..._...._.- -.--..-.-.-. ~_.. .~.. .~'---_.._.--
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<br />HOlme typc:::d, pctntt::d or t>tOlllllJt:",1
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