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PERMIT APPLICATION <br /> UTILITIES LOCATE CONFIRMATION NUMBER: <br /> PROVIDE SKETCH IIV THIS AREA, IF ADDITIONAL SPACE IS REQUIRED, ATTACH TO THIS <br /> APPLICATION. <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 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 properly. <br /> All work 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.zephyrtiiils.Fl.us/public_works.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 Zephyrhills is not responsible for maintenance or repairs of driveways. Driveways shall not alter/ <br /> ��terfere with existing sbormwater treatment and/or conveyance. <br /> PROPERTY OVI�VERS: By signing this application: I certify that I have read and understand the owner/builder disclosure <br /> statement. �i�� (please initial) -} <br /> t ( ` (� 6 ,I ? �` <br /> ,� c � l/j• � �'+'� � � W _ <br /> "4 t _ 1 <br /> ti tLxC,�.,c.,�. c %� ..: � _Y,C�. Y! ��„ (� � f��7 <br /> Applicant Print Name A licant Signature � Date <br /> . ` �� � I y � <br /> Permit Technician Signature (o) Notary Signature Date <br /> Applicant is�personally known to me or produced as identification. <br /> (type of identification) <br /> r°�"R'•":°��o SUSA�!G.WILLIAbIS <br /> Page 2 of 3 A � * MY COhRM15SI0N M EE 003240 <br /> ,, P EXPIRES:July 11,2014 <br /> 9rF„�FLO�° Bonded Thru 6udget Notary SeNices <br />