RC-16-1078Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Parcel Number
Expiration: 11/01/2016
Applicant
1015 NE 93 Street
Miami Shores, FL
MUMMA
Owner Information
Address
1132050150050
Block: Lot:
Phone
GEORGE & CHRISTINA PAUL
Cell
GEORGE & CHRISTINA PAUL
1015 NE 93 Street
MIAMI SHORES FL 33138-
(305)323-8178
1015 NE 93 Street
MIAMI SHORES FL 33138 -
Valuation:
Total Sq Feet:
Approved: In Review
Comments:
Date Approved: : In Review
Date Denied:
Type of Construction: remove
Stories:
Front Setback:
Left Setback:
Bedrooms:
Plans Submitted: Yes
Certificate Date:
Bond Return :
existing floors as per plans
Occupancy: Single Family
Exterior:
Rear Setback:
Right Setback:
Bathrooms:
Certificate Status:
Additional Info:
Classification: Residential
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Notary Fee
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$5.40
$4.05
$4.05
$1.80
$5.00
$270.00
$3.00
$7.20
$300.50
Pay Date Pay Type
Invoice # RC -4-16-59493
04/21/2016 Credit Card
05/05/2016 Credit Card
Amt Paid Amt Due
$ 50.00 $ 250.50
$ 250.50 $ 0.00
Available Inspections:
Inspection Type:
Window Door Attachment
Framing
Insulation
Drywall Screw
Final PE Certification
Window and Door Buck
Fill Cells Columns
Review Building
Review Planning
Review Electrical
Review Plumbing
Review Structural
Review Mechanical
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL, PLUMBINe, ECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNER VIT: I
construc
foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
;�;y� the above-named contractor to do the work stated.
41
plicant / Contractor / Agent
d Signature: Owner
Building Department Copy
May 05, 2016
Date
May 05, 2016
1
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
l •3
Inspection Number: INSP-266528 Permit Number: RC -4-16-1078
Scheduled Inspection Date: September 02, 2016 • Permit TypeResidential Construction
Inspector: Mesa, Michel .
Inspection Type: f=inal Building
Owner PAUL, (;FORGE & CHRISTINA
Work Classification: Alteration
Job Address: 1015 NE 93 Street
Miami Shores, FL
project: <NONE>
Contractor: HOME OWNER
Phone Number (305)323-8178
Parcel Number 1132050150050
Building Department Comments
remove existng floors as per plans
INSPC Passed comments
INSPECTOR COMMENTS False
REPLACE PERMIT RC -15-2462
Inspector Comments
Passed
Failed
Correction
Needed
Re -Inspection
Fee
No Additional Inspections can be scheduled until
re -inspection fee Is paid.
13
ptember 01, 2016
For Inspections please call: (305)762-4949
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Manii Shores Village
APPROVED
BY
DATE
ZONING DEPT
BLDG DEPT
ei1
IJ
SU[3JFCT TO COMPLIANCE WITH ALL FEDERAL
;TATE AND COUNTY RULES AND REGULATIONS
. .
.Y ••
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\,f1,. Miami Shores Village
y • Building Department
BUILDING
PERMIT APPLICATION
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
uniWnVirtrffer
APR i 2016
5-141
FBC 2014
Master Permit No.2CA CO ^ I 01E5
Sub Permit No.
JX3UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION
['PLUMBING ❑ MECHANICAL ['PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
jOrs A) G '5d Sf re
JOB ADDRESS:
City:
Folio/Parcel#:
Miami Shores County:
I I— G'- 0 Ic —005-0
❑ RENEWAL
❑ SHOP
DRAWINGS
Miami Dade Zip: r
Is the Building Historically Designated: Yes NO
FFE:
Occupancy Type: Load: Construction Type: Flood Zone: BFE:
OWNER: Name (Fee Simple Titleholder): efl'tQ' 'G ) • PCwl eta . (1'l (r:tiM .0
Address: [PCS � � c $ c
City: r1,""+�V®�7 State: �![
Zip:
Tenant/Lessee
Name: I, ,
Email: vc\(t 1n� ' e ( �+ ,C (�yFe5. Co, /
CONTRACTOR: Company Name: `cV V t l DC's I Phone#:
Address:
City: State: Zip:
Qualifier Name: Phone#:
Phone#:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Address:
13( Pt -
Value of Work for this Permit: $
Certificate of Competency #:
Phone#:
City: State: Zip:
Square/Linear Footage of Work: 9.% co 0
Type of Work: ❑ Additions, ❑ Alteration0N/V`�ew Repair/Replace
Description of Work: `(t& e !(ep(a (ale [S1 ®c y
❑ Demolition
Specify color o
Submittal Fee $
Scanning Fee $
Technology Fee $
color thru
LSO
Structural Reviews $
(Revised02/24/2014)
tile: P(
Permit Fee $ 0. 00 CCF $�J14• '�10 CO/CC $
Radon Fee $ T o • V
DBPR $ • 5 Notary $ S
Training/Education Fee $ en
•
Double Fee $
Bond $
TOTAL FEE NOW DUE $ z� `1 • SQ
Bonding Company's Name (if applicable)
/74 -
Bonding
Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a rei -ction ee will be charged.
Signatur
Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before a this The foregoing instrument was acknowledged before me this
day of `S , 20 I) , by day of , 20 , by
C.►--t1aS-1 1 -VA
me or who has produced
o is personally known to , who is personally known to
UN L as me or who has produced as
identification and who did take .�4`���tt}t...1I j,l�a
i
a
ir`�• eo •'rl•bs°°.Or�yP NOTARY PUBLIC:
0910 ;aF
Sign: ,per. ri
Sign:
Print: Vii,, •••.•NOISS;.•,,,, , Print:
`/ii41#4111100 �`lor-
Seal:Seal:
NOTARY PUBLIC:
identification and who did take an oath.
***************************
APPROVED BY
(Revised02/24/2014)
*******************************************************************
Plans Examiner Zoning
Structural Review Clerk
e
1
OWNER BUILDER DISCLOSURE STATEMENT
DATE: Ift2f1/4 /DID&
ADDRESS: ID iS 06 434 1 1A talu,l `lo-tes, Py
NAME: 0,11CtStrt(AO- L(. EUl -r
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have
read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner
must appear in person to complete all applications.
State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption
allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the
construction yourself. You may build or improve a one -family or two-family residence. You may also build or improve a commercial building at a
cost of $25,000.00 or Tess (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or
lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built
for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make
sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on
your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and
with -holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all
applicable laws, ordinances, buildings codes and zoning regulations.
Please read and initial each paragraph.
1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner -builder permit under an
exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain
restrictions even though I do not have a license.
Initial ( e
2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and
is not hiring a licensed contractor to assume responsibility.
Initial att e
3. I understand that, as an owner builder, I am the responsible party of record on a permit,.I. understand that I may protect myself from potential
financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the
contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts.
Initial (�
4. I understand that I may build or improve a one family or two-family residence or a farm outbuilding. I may also build or improve a commercial
building if the costs do not exceed $75,000. The building or residence must be for my use or- occupancy. It may not be built or substantially
improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the
construction is complete, the law will presume that I built or substantially improved it for sale or lease,whiich violates the exemption.
Initial Ott r
5. I understand that, as the owner -builder, I must provide direct, onsite supervision of the constructio
Initial
6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It
is my responsibility to ensure that the persons whom I employ have the license required by law and by county or micipai ordinance.
ix
Initial
1
4.
•
7. I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner -builder permit that erroneously
implies that the property owner is providing his or her own labor and materials. I, as an owner -builder, may be held liable and subjected to
serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property. My homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an owner -builder and am aware of the limits of my insurance
coverage for injuries to workers on my property.
Initial CU'
8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the
work being done. Any person working on my building who is not licensed must work under my direct supervision and must be employed by
me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the
Federal Insurance Contributions Act (FICA) and must provide workers compensation for the employee. I understand that my failure to follow
these may subject to serious financial risk.
Initial
9. I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all applicable laws and
requirement that govern owner -builders as well as employers. I also understand that the
Construction must comply with all applicable laws, ordinances, building codes, and zoning regulati
Initial
10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States
Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact tljR Florida Construction Industry
Licensing Board at 850.487.1395 or http j/www.mvfloridalicense.com/dbpr/pro/cilb/index.html
Initial
11. I am aware of, and consent to; an owner -builder building permit applied for in my name and understands that I am the party
legally and financially responsible for the proposed construction activity at the following address:
Initial, PUP
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of inf rmation thymol have provided on
this disclosure.
Initis
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the
Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial
loss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or
employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner -builder
permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of
the contractor's workers compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and returned to the local
permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the notarized signature of the property
owner, or other type of verification acceptable to the local permitting agency is required when the permit is issued.
Was acknowledged before me this al day of
By-Lc-rI
who was personally known to me or who has
Produced there License or <-- Dal II
rit-
OWNER
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL El PUBLIC WORKS
JOB ADDRESS: INS Of 031 6k1 eL4-
City:
SEP 2 5 2015
FBC 20 01(
Master Permit No. fl 1 (5-a
Sub Permit No.
❑ REVISION ❑ EXTENSION El RENEWAL
❑ CHANGE OF
CONTRACTOR
SHOP
DIWINGS
Folio/Parcel#:
Miami Shores County:
lr-39.0s—DVS—vos0
Miami Dade
Zip: 351376
Is the Building Historically Designated: Yes
Occupancy Type:lie`' ° Load: Construction Type: Ta04 Pt Flood Zone: P0 BFE:
OWNER: Name (Fee Simple Titleholder): Ch' 4 aa- Pati Phone#:053 3 E L7
NO
FFE:
Address:
City: 1°k iG,.14 S ht. ceS
Tenant/Lessee Name: ti -DJ i\
State:
Email: Ci‹.6N1rt ... Gl(A Q., t, g e5• Cvt--1
-1431.Ase ()W Nw2
CONTRACTOR: Company Name:
Address:
City: State: Zip:
Phone#:
zip: 33\3�
Phone#:
Qualifier Name: Phone#:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
01 -4 -
Certificate of Com4� p te,r1 C i -
Phone:
Address: City: State: Zip:
Square/Linear Footage of Work: 47$ t/
❑ New
Value of Work for this Permit: $ DU
Type of Work: ❑ Addition ❑ Alteration
Description of Work: 34eMV1re 4.4S-41 ill -j Dogs etz,
p\c n9 co fs (t5c
Repair/Replace ❑ Demolition
�r etyt I �Ied Olila r &
YYl xc 640nem4'! e
Specify color of color thru tile:
Submittal Fee $ • cm Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable) 1014C
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
Signature
OWNER or AGENT CONTRACTOR
The fore ng instrument w acknowledged before me this The foregoing instrument was acknowledged before me this
45 day of . is %.,_, v 1,J' , 20 IS- , by day of , 20 , by
IX11lja = CO -u+\ , who is personally known to , who is personally known to
me or who has produced , , ,� �� _ as me or who has produced as
11 18 ,�I•
identification and who did take an-oatn, ,,,,±,_,_.,,±-,1� identification and who did take an oath.
NOTARY PU LI
Sign:
Print:
Seal:
iT ANNIL'1
IIViay
rI4_
tat
Vass rib
LINDA A. VASSEROT
MY COMMISSION # FF192234
EXPIRES: January 22, 2019
*****************************
NOTARY PUBLIC:
Sign:
Print:
Seal:
APPROVED BY ' G Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: ChIP( 1t)a �'t' DATE: 7J aS1a� !-
ADDRESS: tOtS 0E t' -e' 9-1 1-1,(43.it .1191/e5 a 33►3b'
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have
read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner
must appear in person to complete all applications.
State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption
allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the
construction yourself. You may build or improve a one -family or two-family residence. You may also build or improve a commercial building at a
cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or
lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built
for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make
sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on
your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and
with -holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all
applicable laws, ordinances, buildings codes and zoning regulations.
Please read and initial each paragraph.
1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner -builder permit under an
exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain
restrictions even though I do not have a license.
2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and
is not hiring a licensed contractor to assume responsibility.
Initial
3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential
financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the
contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts.
4. I understand that I may build or improve a one family or two-family residence or a farm outbuilding. I may also build or improve a commercial
building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially
improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the
construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates the exemption.
Initial
5. I understand that, as the owner -builder, I must provide direct, onsite supervision of the construction.
Initial
6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It
is my responsibility to ensure that the persons whom I employ have the license required by law and by county orau unicipal ordinance.
11.
Initial ► l iY
7. I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner -builder permit that erroneously
implies that the property owner is providing his or her own labor and materials. I, as an owner -builder, may be held liable and subjected to
serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property. My homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an owner -builder and am aware of the limits of my insurance
coverage for injuries to workers on my property.
Initial
8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the
work being done. Any person working on my building who is not licensed must work under my direct supervision and must be employed by
me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the
Federal Insurance Contributions Act (FICA) and must provide workers compensation for the employee. I understand that my failure to follow
these may subject to serious financial risk.
Initial
9. I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all applicable laws and
requirement that govern owner -builders as well as employers. I also understand that the
Construction must comply with all applicable laws, ordinances, building codes, and zoning regulati
Initial
10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States
Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the Florida Construction Industry
Licensing Board at 850.487.1395 or http://www.mvfloridalicense.com/dbpr/pro/cilb/index.html
Initial
11. I am aware of, and consent to; an owner -builder building permit applied for in my name and understands that I am the party
legally and financially responsible for the proposed construction activity at the following address:
Initial
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the i formation that I have provided on
this disclosure. Qom,
Initia�
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the
Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial
Toss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or
employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner -builder
permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of
the contractor's workers compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and returned to the local
permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the notarized signature of the property
owner, or other type of verification acceptable to the local permitting agency is required when the permit is issued.
Was acknowledged before me this day of
By Pat srn - tACGI P T L' who was personally known to me or who has
Produced there Licens
OWNER
L lQ;c- N St as identification.
RY
itNotary Pudic State of Florida
Sindia Alvarez
4 My Commission FF 156750
F ir" Expires 09103/2018