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PER.MIT APP�SCATION <br /> UTILITIES LOCATE CONFIRMATION NUMBER: <br /> PROVIDE SKETCH IN THIS AREA, IF ADDITIONAL SPACE IS REQUIRED, ATTACH TO THIS <br /> APPLICATIOI�l. <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 rndes shall take precedence over all <br /> approved wnstruction 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 dces not ensure compliance with deed restrictions and I understand that additional deed <br /> restrictions may apply to this property, <br /> Alt work shall comply with the current Florida Building Code, Public Works Design Manual and FDOT Design <br /> Standat'ds(if applitable). (Public Works Design Manuai online link: www.ci.zephyrhills.fl.us/public_works.asp) <br /> APPLIG4TION IS VOID UNLESS SIGNED WITH PROPER IDEN7IFICATION AND WITNESSED BY A PERMIT <br /> TECHNICIAN OR NOTARY PUBLIC. <br /> NOTE: The City of Zephyrhills is not responsible for mainbenance or repairs of driveways. Driveways shall not alter/ <br /> �^terfere 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 /> �`7� �.'�`j r �+ �� �,�,-�/1����, t� �,,� <br /> 'iu'" < '��� tL <br /> Applicant Print Name A hcant Si nature �(� Date <br /> , � (� � c..-, � E —� <br /> Permit Technician Signature ( ) Notary•Signature <br /> Date <br /> Applicant is personally known to me or produced as identification. <br /> ,t�aY.v�e�, �Sp��yy��p� (type of identi�cation) <br /> c <br /> � ,� N1Y COMMISStON#EE 003240 <br /> EXPIR�S:July 11,20i4 P$9� 2 of 3 <br /> r�9TFOF Fl�e Bw�dGl'TMu BUbgC!NOte(y$ervIC6S <br />