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WS-10-19-2499
. �����������:��a�� 1 1 � 5 I�� 1�ijl� � �s 1 ��I � r b�A� µ�w��A : � ��, � � � � � � ����R��� ��� �� 1C3IlSQ P+3.�.2nd Avenu�,tv9i�mE Shar�s,F1or(t�a 331.�8 °�~~-�.�~.�� i'�I;(3C�Sj��5-22t�F�x.{3C��}756-£i972 [P�SAE�`f`IC��E ta1€�£P�it��iE�iltlVl�ER;{3t�5�752-49�� � � � 1 ��5'�@�'P�CRI'�!� k�l�, ��"" ��� �„`t���°�� � � � Sttk3 P�t"tl'!tt h1�?. ���€�.�E�v� � ��.�c�r��c � R���ir�� � R�v�s��� � �x�r��s��� �����w�� [���.un����� � n��c����c�� ���a���c wc���s [� ca����� c�� � c��c�����r�c�� � s��� ���-r�;��-r�� ���w���� ��������ss: ��c� �v� s� �r����r Gi : Niiarni Shc�res �c��ar�� � �iiami (��de Zi : Fulia/#'arc���t:�1-31 C�1-f��5-f3Cf`]Q k��h�E�u�ldir��F#�staar�e�fEy Des��r��►t�d.l�es NC} � � OGGl3�}�fiC�T}#�}L'; I�E� Ltlt3t'�: Ct?C2S�FUC�Ipft T�(J@: CF�.3 �I£3QC�ZGtt't�: `� �FE: I�Ic� �FE: ��J.�� . PE�2CY �tI�LP�RTEC�A!J�N�IFER CU�R1S .561-�36-997Q C}1�1�ER.Name{�e�Simple Titi�hc�ider}: Phc�ne#, �ddress.��46 �VU 22 �T City: C}�VI� St�t�: �� ���. 33'��4 T�n�t�t/i.�ss��Name: nl� Phane#: �la Erriail. P�N1R121C��tViAIL.�C�M ��IVfi �T�R:CaampanyN�me. � ���� ���L!�����r° '� ��a ���» Phe�ne#: ��:�m ���?��€�� ���r���: ��� � �C�C��'�t �� ��'�� � ��s� �� �aty: ��.t��� �" scaee: F`� zEp. ���,�`� G2ualifier(��m�. ���� � �� � � �� �� Ph�ne#; ���� ����' ���� � St�t�C�rtif��at�c�n c�r R�gis�raiic�n#: � �� �.��.� �.�� Certifica��c���omp��ency�: (3ESI�tiIER.�rchite�t/En�in��r: `'�1�.`'` Phc�r��##; �;.'��,�� , ��""�� ��" Address. �� �� ��' � ��'� �i�y: � �f�a� � S��t�: �� Zip: .���g.��` l�at�se�f 1�t�rk for��Sis Perr�dt.� �`�, �`t�� Sq��r�f i.�r���r� i�ge�f 1N�rk; Tpp�of V�dcark. � Addition � Alt�r�Cic�n ❑ New � Rep�ir/Replac� � (�er�oli�isar� scrip�i�r�czf tNork: 1 � � � ��.AJ� � � ������.� ��1 T S���i c�lar c�,f c�I��thr�t til�. su�mic�a��ee� ���mac� � ce�� �ca��c� �ca����,����� ��a���e�� e����� �vot��s Teehr�c�lo�y Fee$ Trainin�/Educ�tion F��$ ��ubl�F��� �tructura!Fi�view�$ ��and$ '�t?7`�L FEE�it3ltJ UtJE� {fdeviseda2f24�2aSa) �ondin�Ce�mpany's ht�m�{if�pp9ic�ble� � �andir��Carnpany's Adcfress � _ City �tate Zip IVlort�a�e l.�nd�r's Name{if applicable� �1� (�rtc�rtg��e�.ender°s Add�ess �l`� �ity Cl1c� State i��� �!�t1/c� �.. Applicatic�rr is P�er�by rrrade tc�e�btain a permit tr�dc�the wc�rk and installatic�ns as indic�ted. ! c�rtify that nc�uwc�r�c�r installa�ic�n h�s caammer+��d prinr �o th� issuanc� p� a �ermit and th�t all war� vuill be perfc�rmed tca meet the star�darcis c�f a�! iav�rs regul�tin� construc�ion in tl�is jurisdieti�ar�, I untierstand that a separate �ermit mus� be s��ured for EI.�Ci'RE�£ PLUMBI�lG, S1�NS, P�CI[�5, Fl1R�tA,CES,�bIL�R5, NEATERS;T�RIKS,AIR Ct�Ni�(TIC7NERS, ETC..... C�UVV�ER°S AFFE��VI�'. 1 cerCi�y that �il �he �c�re�pie�� ir�f�ar�naCE�n is acc�arat� and that aIP u,rork�nri{I be da�� in camplianc� �rith a31 app#i��b1�la�rs regulating consCruc�iar�and zcani�g. rr �! �� � �� Q ���a '�Q�� �4�i��..��� T� ���Q� � ��'���� �� �Q ���� � �' ,�� ������ � ���� ������ ��� ��� � ���������� �� ���� ������ � �� � � � �� � '�� �B�T���l �1�1l�lI��IN�' �f�N���.T ET� 1°Q�1� ���L��� �.�ll� �TTQ�I�EY BEF��E �E�C� �IN� �Al1R N T10E �� Gt� EIt�CE ��IT.,' lVc�ti��tc�A�apti�arrt,• �1s c�ccanditi€�n to tt��issuearac��f a buildan�perrr�it vui[h an�stimated vcaJue�xce�ding$25�Q, the c�p�tica�nt n�ust prornfse irr gocad faith�hcrt r�ee�py af t�e nr��ice nf ccarrrrrrenc�rrieni and constructfon lien fa�bre�chure �vii!b� deliv�r�d ttt th�person v✓Paeas�pr��aeriy r.s subject to ntrachrrrent. ,�t�o,a certifr'�d er�py o,f the r€c�rd�^d noiice of�c�rr�m�r�cemer��rnust b�pcastec�cr�the jca6 sitc� �r tlh�f rs� �r�sp�cFic�n wts�ch-rrrccurs sev�r� (7� days crf��r ehe �tlilding �a�rrr�iL is issu�c�. lr� f�� crbsence r�f such pc�s��d rttaFr`��, the insp�eti�rr�i(f r��t be�rp�araued r��n�a r�ti�p�ctiar��ee wtl�b�charger�. . � ; , � r r= �: � ' , _��, ;� � �,�f . � t � <� � � � � � �a ,� , r._ � �..���, ,, _� ,�° " ,a���, � �~�' Si�r�atur� � � _ ai�natur� _������ �' ��.____. _.._.e �(�UVNER c�r AC�ENT '�f } GQNTR�C`�OR t �''` . The�oregeair��instrumenC sv�s acks�e�w(�d��d k�efo�e me this Tt�e f�ar�ir��ins�rument was ackr�c�wl�d��d befoe�me this ���t ��v of �`$ za��.._.,�� � c��y at_.�t $ z� � , t�v ��`��___��__.._.—..��, _ �;�--___----_, � � .� � ��-�G� � ���v����t ��ho is p�rsc��,aE1y knovvn�o �"�' � �"� ,who is � a4��- c� ' t.r '� � ��s�"°� me or wt�o has r m��ar wha h s prc�du� -�' �� " �� p €�duc�d as �.�_.� identi�ic�tion�nd�+rho did take an oath. id�ntMf}eatio��nd who did take ar���th. ��� N�TARY PU P Pt�Tfk�l"Pl1�LI�: � l„ � �����,�k 'y .n �^` �k�li. ��,.. �! ,f �f�tl: .�° `-� � � � � _ �((�tt: � �...1 +� u,l 1� � � 'd�Y�`Y�G{,� �t't��: xg`���r���`': M,4�iAAtiz`}�'A�E:3US �� �' ;c- t�:e r�, �in>U �� $EaE: ° � ` t�'�us�rt r GG ��t_•s ���� Not�sr�+�"ukzt���t�t��at FEc�r€d� S�al: �,. "�t�� , .t$S4FS hfl�ea€fPt@fR�i�E@ '�u a t N��L.o,nn:C�.�uesAu�t`�'G2t `� « My�.�amm�ss�on�G tfl57t3 ," �*'�ares�� Exp+rea 031t3t2U22 �����z��m�:���� � � * t��*�����z����*�z���������a����+������e+�s��������w*��+������������w�� ��� �� ��� � ���r� �PPRt�VED BY � �- � Plans Exami�er Zonin� f Struetural Revie� Cle�k (Re�isedfl2��A/20]�)