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P�RMIT APPLICATION <br /> UTILITIES LOCATE CONFIRMATION NUMBER: <br /> PROVIDE SKETCH IN 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 applicabie codes. I understand these codes shall take preoedence 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 additionai deed <br /> restrictions may apply to this property. <br /> All work shall comply with the cument Florida Building Code, Public Works Design Manual and FDOT Design <br /> Standards(if appliCable). (Pubiic Works Design Manual online link: www.ci.zephyrhills.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 /> intertere with existing stormwater treatrnent and/or oonveyance. <br /> PROPERTY O N,NV�S: By signing this application: I certify that I hav� read and understand the owner/builder disclosure <br /> statement. f1 " (please initial� �� i ( �� -}, <br /> � ;��iG :,, ���ti��f� �� ti�� dV?�.-v�--- � � ��` :cf `f- .}_, <br /> Applicant Print Name A plicant Signatur Date <br /> ll l � � �� <br /> Permit Technici n Signature ( ) Notary Signature Date <br /> Applicant is(�'�personally known to me or produced as identification. <br /> (rype of identification) <br /> ,��P�B�. SUSAN�.WILIIAI+�S <br /> 2��•��• c* t�1Y COMMISS�ON�EE 003240 Page 2 of 3 <br /> * EXPIRES:July 11,2014 <br /> s o� Bonded ThN Bud9et No�ary 5errices <br /> '9TEOr ct°' <br />