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PERMIT APPLICATION <br /> UTILTtIES LOCATE CONFIRMATION NUMBER: <br /> PROVIDE SKETCH IN THIS AREA, IF ADDITIONAL SPACE IS REQUIRED, ATTACH TO THIS <br /> APPLICATION. <br /> C�'� S i � ;,��, ,'�7�/ <br /> AFFIDAVIf: Application is hereby made bo obtain a permit bo do work and ir�tallations as indicated. I certify that a!I foregang <br /> inforrnation is acxuratie and that afl work wili comply with all applicable oodes. I ur�derstand these codes shall take precedence over all <br /> approved oonstivction ciowments,ar►d is�anoe of this permit is verification that I will notify the property owner of Horida Lien Law <br /> req.,F.S.713. <br /> The issuanoe of this permit does not ensure complianoe with deed restric0ions and I understand that additional deed <br /> restricdons may apply to this property. <br /> All work shall aomply witls tl�e cument Fbrida Build'mg Code,Public Work.s Design Manuat and FDOT Design <br /> Stsndards{if apptiCaWe). (Public Worlcs Design Manual online link:www.d.zephyrfiills.fl.us/public works.asp) <br /> APPLICATION IS VOiD UNLESS SIGNED W1TH PROPER IDENTIFlCATION AND WITNESSED BY A PERMIT <br /> TECHIVICIAN OR NOTARY PUBtIC. <br /> NOTE: The City of 2ephy�ifills is rwt nespor�sible for mainbenance or r�epairs of driveways. Driveways shall not alter/ <br /> interfere wnh�ng sbormwa�er tr�eadnent and/or oonveyanoe. <br /> PROPER7Y O RS• By signing this appliption: I oertify that I have read and u nd tl�e owner/builder disdosure <br /> starem�,t_���. cr�lease�r►itian <br /> Ct�v�N<��c--�-- �o��s, ,,,,c " G�/G�/ �a �6` �;r? <br /> APP(ir,arrt Print Name Appiicarrt Signature Dat+e <br /> Permit Technician Signature (or)Notary Signature pa�e <br /> +4PPlicarrt is( )Persor�a�lY Imovvn bo rr�or produoed as identification. <br /> (type of ider�tification) <br /> Page 2 of 3 <br />