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<br />A. NOTICE: CF 'JEED "ESTiCCl10:JS
<br />The ':ndQrs~3ned understands th~t this permit m~y be s~bject to "d~gd re~tric~l~n$~ \~h ~h
<br />mai' b9 x.ore :::'Estri,~.tit?6 tr'li~tl City regi)_lati6n.5. The lJndersig:r.ac. <39SlJ.meS I'9spo~"j,git,~.li":.y fer
<br />,-:::~)mplJ..aflc~ -;-ri':t! ar.y arpl':';'2able deed Ie=tricti()~lS.
<br />]a, DNLICENSEG CO~l'r?ACTORS AHO C:ONTRAC'::'-:lP. RE:Sl'ONS!1\ILI":'IES
<br />If the :)~.rr~e:: tla.'3 tired e, :::cntractClr or cC:-"ltrantC'lr.~ tOIJ.ndertak~ ';,j(:.::k, they r:.i.'~_Y t)e ~~eq1..l~:::8d
<br />~0 be licenge~ ~n ~ccordan=~ wttt stat~ and 10091 re?~~~t10~&. If th~ Oon~La~tor is ~~ot
<br />l.J,.cen.sed as ::eq".tired .ty lairl, bot}: the ClWnE'r and cc.ntr.actcr I!'H9.y be cl.ted f:.:'.::= a misde~(\~,~r)or
<br />violation under ~t~te law. If t~e cwrl~r or i~tendQd contractor a~6 uncertain as t~ what
<br />licensi,ng re~uirerr,ents mC',~' .apply fo:: th!! i:i.ter~d9d \I-Icrk, they ar~ ad~....i~e(i tc ccn-::actche
<br />::;,i.ty c-f Zeph'lLhills 9clild1ng :)"p.art"$nt, 813-~80-VJ,W',
<br />F\:~thermDre, if the O~Jner ha$ hired a ~on~ractor cr contr$cto~~, h~ ~s advi~ed ~o hav~ the
<br />corltrdctor(g~ s~gn po~ticns of the -~Contractcr Secti=nB~ of this 3pp:icat~cn ~or whic~ ~h~y
<br />will be resp~ns~blQ. If Y~Ur as the o~ner sig~s as the oo~tractor, y~u 2rg indicating that
<br />l'OI.:!.!" rather than the :::::CJ"ltl"'~c't()r, are respon:3ible for ;::he ""OLK. tf the contrz,::,tGl.' t.JiSt'1-ee
<br />YO'.l to sign as c,:)ntr.a::otol::' that may be an irJ.dic~t.i':'r.. t:h~_t hB is not prQP:5rly ~:i.C>:ln!,q!:d. and 1.$
<br />not ent~tl~d to pe~n1tting privil~g~s in t~a City o~ Z~phyrhill~,
<br />'-, 1R.\:-IS20RTI\.T::GN IMPAG'C fEES hI;::; U'ELITYcONNECT:ON ,"/!'ES
<br />D, CO,13rl\UCTnION LIEN LA',iI ,:CHi'l.V;gP. ~~,3, FLORIDA STATO':'ES, AS P.MEFD8Di
<br />I r.>ertif'j th9.t I, th~ ~pplicant,. ha'JE baeI.!. pro1.rid.iQd \f;i-;:h a CCpjt ..)! "~'lc.rida' s Construct:inrI
<br />lie.r, La~'" - P.':'Ir.eol..,nGr's Pr-:;.tectj.CL GtLi.de" prSlFQ.riltd. by -:1-.& f'lo:t'ida D~p:5.:::-:-m~nt of A.9ric'Jlt\u'.~
<br />a~d Consunler Affaire. :f the applicant is someone other ~hat tha "orlnerH, ! cerify that I
<br />he:ve obt~ined 0_ GGpy-:;f t.he abovl'! oEls..::.tibed doC'ume:nt and pr,:):ni$e 1i. ';Jc<:rd f3:...t.h t:~} Ij""ji",,;,,t:
<br />it t~~, the \'()\';ner'f [Jrl.or to com,.Tft€ncen,ent.
<br />E. CONTRACT'OfV S/:)\-J'NER~ s ~FF:DA'/IT
<br />I c~rt~fy that all the infcrn~tion j.~ this application is a~CI~retB alld tha~ a~~ wcrk wi:l
<br />t',e acne in (:ornplianc<? vJith all applicable lal-.'s rf~.g.'Jl~ting L'ons'_~''"ltction, zon.i:1~J, and. I-and
<br />oliiilTJ'alopmen't.
<br />Ap:?li(~ati(ir-~ is he:t.eby rf:ade to ob,,:",.=?in a permit to do v:c.J:'k .arid installation a.9 ind,i,ca":ed. I.
<br />::,e~t.lfy that nl.)~v::::rk~~: insta:i,l~-::::,.:.on }-JS~ c:""rT'..:"MH1:::,ed. p::::1.:;,r t,) issuance of a pe..r':l'\.iT~ and that
<br />al~ work will be ~erfo~med ~o meet standards of ~l: law9 reg~lating ~cnstructiont C~ty
<br />cedes, 2:)ni.,.;r r~gulations, and land c~\"~lopmQ(':t: ~'equlation$ in the jur.i,edic't.iGn. r alsG
<br />certify .tb~t I understand th.at the r.'eg'.:r.la":':":;)fl;Q of other gc,:rernrnental a.Qer.cie3 :rr.f!Y apply t::-)
<br />the. inl:.en:-le.d ~'I()rk, and tr..2-1: it is m:,' respc'n9io~li"Cy tc .ldcr.tif)l ~hat a':t~,,:)n& 1 rrn.o.~t ts.ke t.,
<br />be ,10 cc,mpl.l.anc€. S,u~h agwnr::ie9 :i:l::ludQ: bl,.:lt. ara n.:.t limited t.c: wDepa:r."":t1~p-;: of
<br />En.iTl::oI:p.tsn.,:.s.l Reg'.llati~n-.C.:rpres:e 3.!.?hBc:.ds, We~.:..ar\d A:C"ea~ a!"..'j E,:r.vlr()nrn~nt~lly Sen!lit.:''l'J~
<br />Lands, Water/Wa6t&Water ~re~tffi0nt
<br />~So-J.th""fe:tt F10:r1da v;:at~r Manageme::-Jt D.i.str.1,C't~~:e::'lG, C:rP:t-e!'J~ BayheHds, i-';etiar.d A.r:eas.
<br />Alterihg Watercourses
<br />"'krmy C':'Ir:.ps 01: f:(,gineera--Ses~Blll~, Dcck5i, N.:-..viqacle Nat;.a,n.;rays
<br />~Depa:ctment of H~e_l tli [~ F.ehabili ta t:~ ;le Ser-,,-,i. e>€S ( Er:.~_rirc':!mant~l :-1eal.tn en:,;. t .-v.'eJ.ls.
<br />"jv~st.e\-I;,ater TrQ&'cnerl't, Sept1c 1'ank.=
<br />*0. S. Er~vi:corl'mer~.t.~l Protection ~~get::-~~:i-r"l.:3bestos abat-a,tl':er:.'t
<br />I also certify ~hat, if f~l_l m2Ler~al i9 to ~& ~eed in ?l~Cd Zone "A" cr ~A,etc.n, jt i~
<br />understood th~t a ,jy.aine!ge Flan add.rEssir.g Ei "'(..>::>TF6::1.3a7~_ilg volum~" \0/)..11 be :5'.J.brr:it.t.ed .."ih~.ch
<br />i5 pxspared by a professional e~gi~~e~ I:egistered in the St&te of Florida ~~lor to rer~it
<br />1.$9.'J.anCe.
<br />A per~it i8sued shall be CODs~ru~d to be a lice~se to pr?c~&d with ~h~ work and not as
<br />au~hority to violate, ~~ncel, alter, or set asid~ any provi5lans of the t~chnical cede~,
<br />nor shall issuance of a penrd..: prevent the 3'~4ildinQ' Off~.c:ial fLom the":,,..tte~ J:"'e':;;'uirin9 ,'l
<br />co.t:-re'~.;tion cf errors- .:.n pl.ans, =::n.Sf:.j::Uct'i:::L, r".::l.. vio:"a.tions \")f any c.:-de. E;".'€ry per-rnit
<br />issu.ed s'cJ.al.! become inv9.1 id un~e5:5 th€ ..,lork aut ~ori :1€,>'j bv !:uch pettr.1 t. i5 '::OlTJTI€:oc..::d .....:i thin
<br />si)( m~)nth~ of i$s'.J.3nce, 0r if l...,o::::".t 3.ut:-.or1~~,j by '":l"~Cl pG.r~.i.::'3 ~llspended :::.r aband~')ned fer a
<br />perlod of sLl(' months -after the tiITi.Q ttle i'Jerk i& conH':'\enced. One 90 d.ay exten..si(J(l of. :i:nE'
<br />may be allcwed for ~he F~rrnit w1th fee oharge of $15.0C. The exteI1~~0n shall te raq~eeted
<br />J_n ~"'rit.ing -':0 t.hs- Bl1i2.din9 Gfficial. An $pprc-.red .i~l.sp~("tion :nu~t b~ legged dL.lrii~J each os_x
<br />nlonth per1cd, or thg project will be con3id~red abandcned.
<br />WARNING T(, OWNER, 'tOUR r.'AILl'l',';; T(J PECORe A l'lC1Tlc-r Of c')[,n,lENCElclENT MAY R;;:SLJL:' n; YC,Ui'(
<br />PAYING tWIC.E FO~ I!'--lPF.OVEl'1ENTS ':'C "{(YJn PRCPEF.'r'j.'. 17- YOtT rUTEN(; 'to :JB'::'J\TN FIN"AN-:IHG, CON,sfJLT
<br />';'lItH YOUR LENDER OF All ATTORNEY 8EFORE RECO:RCIN<3 YOUR No-rrCE OF CO[,~(-1,,('lCEI"JEllT, ,J038 UNDER
<br />$2, :'00 IN VAL:JE DO NO': NEED TO PECORD AlIC 20ST A "N')1'I'~,; OF ccr'111ENCEl'IE:NT",
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<br />SlGl"ATC;RE:; GONTF,ACTOR
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<br />SI~NATUR~: OWNER OR AGENT
<br />
<br />STA'!~ CF FLCIRIOA
<br />COUN?'i OF ..______~__..__..__
<br />~he for~going lnstruffient w.s ackncw~edged
<br />d@:fore rile t.his __ d.;.y :.::f __, 2~
<br />by
<br />~n3reQ of oerson acknowledged)
<br />o wrc0 is p~rs~nal:L)J knO'i"in. t:J tri.e, or
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<br />STATE OF FL~RiDA
<br />(:OUl-:TY (:":
<br />fr:h~ fcregoing- ifl:!!!tru!T:ent "'-'as acknowl ~cg~~l
<br />Befere ",,10 thi.. __day cd -----, ;,0_
<br />by ______
<br />(r..aJil80 of f'6rson a;~:'o::0~.iled'Jed)
<br />OJho is p-e:.csoflal":..y .:<.nc.'i~Jn to me, or
<br />
<br />o "ho has rroduce,;i_______
<br />(typ~ cf iderltifi.Cation}
<br />ar::J l,.,h:)Odid Oc.id not take: arl ~Jatn,
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<br />C ~:~.~0 has P':ColjLlced ~~____
<br />(typG ~t identification~
<br />..nd '.h,) Odici []did r,:>t' take a.n oath
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<br />Sig~c.t.urEc> of person t.ak.ing a:::kno'..-ledgerr.ent
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<br />8i::;Jndtu::.~ of per;sct'~ tai<.,:J...ng a;':"J\_11oNle:d'lTI"tf,1,::-!t
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<br />!larr.E: typw.d, printed C~ stamp~(J
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<br />U~If,~ 't~'p-=d, pr _int::ed cr ~tdmpe"J.
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<br />~: 'd
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<br />j:j'Jf"Jfj
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<br />Sll1Hd!Hd3Z iC AliJ
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<br />1\~~t:6 :::0
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