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�E�rr aPP�cwntoN <br /> UTIIITIES 1.OG4TE CONFIRMATION NUMBER: <br /> PROVIDE SKETCH IN THIS AREA, IF ADDITIONAL SPACE IS REQUIRED, ATTACH T� THIS <br /> APPLICATION. <br /> �C'_� � � �'��/ <br /> AFFIDAViT: qpplication is hereby m�de bo o�in a pemut b�dp work and ir�allations as indicated. I oertify that aN foregoing <br /> i�fo�rnabon is aoc�rabe and tfiat all vMOrk wNl aomply with all applicable oodes, I understand these codes shaQ take precedence over all <br /> app��°D�O�d�merrts,a�d i�ua�oe of this pem�it is verification that i wiill notify the property owner of Horida Lien Law <br /> req.,F.S.713. <br /> The issuance�ti�is permit doe.s not ensure oomplianoe with deed r���and I understand that additional deed <br /> re.strictions may apply to this property. <br /> All work sf�all oomply with the ament Horida BuiWing Code,Pubiic Works Design Manuai and FDOT Design <br /> ��dsrds(if app�kable). (P�lic Works Design Manual online link:www.d.zephyfiills.fl.us/public works.asp) <br /> APPLICATION IS VOID UNLESS SIGNED WITH pROPQt IDENTIFICATION AND WIT"NESSED BY A PERMIT <br /> TECHNIQAN OR NOTARY PUBLIC. <br /> NOTE: The Cih of Zephyrhilis is not r�capo�ible fbr mai�nanoe or repairs of driveways. Drivewa�rs shall not alter J <br /> inberRene vrith existing sbo�mwater tr+�t arM/or wnveyanoe. <br /> PROPERTY OWNERS: By signing this application: I ' that I have read and nd tl�e owner/►xjilder disdosure <br /> statement (Please initia� <br /> ��'" I.c���i� ��°�1� Z� ._ � �., `G �j� <br /> Applkant Print Name�` npplicarrt siynah,re / <br /> DaQe <br /> Permit Tedmician Sgnature Ca?Notary S+9nahme Date <br /> Applimnt is( )Per,onaly Iv�own t�me or produoed as ider�tification. <br /> (tYPe Of id�tdfication) <br /> Paye 2 of 3 <br />