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zPERMrrAPPLZCATION <br /> UTILTEIESILOCA'TE CONFIRMATION <br /> cPROVIDEISKETCH aim 'THIS !AREA, IF ADDrCUJNAL 'SPACE IS REQUIRED, •ATTACH 71:1THIS <br /> APP LICATIO N <br /> • <br /> • <br /> A406Z 5 <br /> • <br /> OL. <br /> "•c5 A <br /> • '` <br /> • • 1°_,StI>X14)44 ui/elcrimus(opLP-Ase) <br /> • <br /> )T A4* g. ee.. 17 <br /> L'? <br /> Cc-+,v -C4441 Car 4.>/ <br /> /7,00 >0 4i# 7ez/46 (Age <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 thatl 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 applyto this property. <br /> All woric.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.fLus/public worics.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 Zephyrhilis is not responsible for maintenance or repairs of driveways. Driveways shall not alter / <br /> interfere with existing stormvvater treatment and / or conveyance. <br /> • PROPER W ERE: By signing this - application: I certify that I have read and understand the owner/builder disclosure <br /> statement. - • (please initial) <br /> • afite.r • Cy ey I I- 30 -of <br /> Applicant Fyint Name App nt Signature • Date • <br /> Cu_ /464144)/f /1-30 - 09 <br /> Permit Technician Signature (or) Notary Signature Date • <br /> Applicant is ( ) personally known to me or produced • • as identification. • <br /> (type of identification) <br /> Page 2 of 3 <br /> _ _ <br />