1022 NE 91 Terr (2)PROPERTY OWNER
Name 1 ( A ; ,U
Address
/02, /V ,9/ 1�2
Home Telephone
Business Telephone 3 757 f ¶ 7 (t .� _ __ (e s
r t0 / fT v "`^
Fax
TYPE OF MANAGEMENT (✓ )
New Construction
D
Enclosure
i <
Alteration Exterior
Electrical
Repair
Alteration Interior
Demolish
Plumbing
Relocation of Structure
Shell Only
Foundation Only
Public Works
Add'l Attachment
Other
Add'l Detachment
Building Official
Other
Vr <�
SECTION
BY
D
Zoning
i <
y/
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
��
Vr <�
Page 4
OFFICE USE ONLY
CHECKLIST
D OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi - family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.)
Inspector State Educational Fund
State DCA (Radon)
Code Enforcement Fine
Zoning Review
Notary
••• •
• •
• •
••• •
•• ••• •:• • •�• •
4 • • •■• •
••• •••
•• •
•
•
❑ PROOF OF OWNERSHIP
•
.• •.•.•,: ;. •
• • 0, “RS / bPRM APPROVAL
(Septic / Sewer)
❑ IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
PERMIT FEES
$ 60
,6a
$ (¢.005 /sq.ft.)
( x .6U 1000
)
(¢.01 /sq.ft.)
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
• BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
TOTAL $ ,� o � (�
ISSUING OFFICIAL
REVIEWED AND PREPARED BY: DATE:
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 - 2207 • FAX (305) 756 - 8972 • http : / /www.miamishoresvillage.com
Step 1.
Job Address:
Folio Number
Lot Block
Subdivision PB PG
Current Use of Property
Proposed Use of Property
Tenant Information
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
• • '- •
Flood Zone
• - - ••• - - - • • • • •
• •••
PERMIT APPLICATION
• Mastpr IV$rrit • • .
•.subsidiar Perr7irtNo..
. • • •
•
INSTRUC'T'IONS - 'I'he following steps must he taken to obtain a permit from the Miami Shores Village:
• • • • , •••
Complete the attached permit application which must be signed'bIttte pr2 pgrDCownes Q?lifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of yodt applicaIiod..If roofing work wilt be done, a roofing application must be submit-
ted along with this permit application.
• • •..
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
414— Address A City � (12/(4°Pt Zip
Description of Wor � t.r� f_c L 4o/r/
Zoning Linear Feet
Square Feet
Value of Work 300 ' Bldg Value
Tax Assessed/Appraised Value
Units Floors
Base Floor Elev.
ENGINEER
Name
License No.
Address
Telephone
Fax
CONTRACTOR
Name
License No.
Address
Telephone
Fax
Qualifier Name
ELECTRICAL
TV'I'I?
Minimum Fee
QTY.
TYPE
Dryer
QTI.
TYPE.
Outlet, App idhct • • • •
QTY.
TYI'I{
Service Repair
QTY.
A/C Central 1 -3 Ton
Fan
Outlet, Wall
Service, Temporary
A/C Central 4 -7 Ton
Fire Pump
Outlet, Switch
Signs
A/C Central 8 -15 Ton
Fixture - Fluorescent
Oven
Space Heater (kw)
A/C Central 16 -20 Ton
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Heater New
MECHANICAL
TYPE
Minimum Fee
QTY.
TYPE
Condensate Drain
QTY.
TYPE:
Generator
QTY.
TYPI?
Refrigeration, Tons
QTY.
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C WaWWin. Tons
Dryer Vents, Number of
Paint Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
Process/Pressure Piping
Supply, AC Well
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
Temporary Toilet
PLUNIBING
TYPE:
A/C Condensate
QTY.
TYPE
Drains, Roof
QTY.
TYPE
Miscellaneous Fixture
QTY.
TYPE
Soakage Pit
QTY.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 2
STATE OF
X gnature of
Print Name
Sworn to and subscribed before me this /3 day of 1/1414. )
( -60
Sign
SEAL:
• •
• •
• •
•
••. •
I�
kv7H 5A7 NgaS •
lire of Notary Public
•
• •• • :
• • •
• ••• •
••• • •
;. ,L NOTARY SEAL
G:,AI)YS J VILLAR
StateofFlorida c K _c :,1M16 '�NNUMBER
u *,'' OD091094
;0 Q,, tt' GO'r+ 3SION EXPIRES
. t AR t 2006 ____ z
•••
•
•
•
PERMIT APPLICATION
IMPORTANT NOTICES
•
1. DO NOT BEGIN ANY WORK WITHOFJT41AVJItIG REC�EIVEDYOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS Off` CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holiday . • • •
2. All construction of demolition areas MUST 44 MAMAIfAI IA AC1:FgN, 11ifATAND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL Dn3( r R£ETRVM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM IVING DAMt G D EQUtPMEIQT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk• • ' • •
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, certify that all
work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
are required for ELECTRICAL, PLUMBING, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to yo `r property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1° Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
IDA, C • UNTY OF MIAMI -DADE STATE OF FLORIDA, COUNTY OF MIAMI -DADE
Signature of Contractor / Qualifier
Print Name
Sworn to and subscribed before me this day of
Signature of Notary Public - State of Florida
SEAL:
Personally known OR, Produced Identification Personally known OR, Produced Identification
Type of Identification Produced: pi. ' S301. (vJ r ?P 'S / J - 0 Type of Identification Produced:
Page 3
• • • • ••• • •
• • • • • • ••
••
•
• • • • • •••
• • • . • • • • • •
•
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being perforrMd ant'qua$tity(k;) in the space provided below. I
RECEIVED AND REVIEWED BY: DATE:
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 3/14/2003
Applicant: JUAN
Owner: SANTOS
JOB ADDRESS: 1022 NE 91
Contractor
Local Phone:
Per t Status: APPROVED Permit Expiration: 9/9/2003
Work: EXTERIOR PAINTING AS PER AGREEMENT
Sign
Signed:
Building Permit
Permit Number: BP2003 -413
SANTOS
JUAN
TERR
Contractor's Address:
Page 1 of 1
Parcel # 1132050010300 Legal Description: WATERSEDGE PB 9 -141 LOT 3 & E15FT LOT 2 BLK 2 LOT SIZE 65.000 X 125 OR
Fees: - Description Amount
FEE2003 -1545 Building Permit Application Fee $60.00
FEE2003 -1546 CCF $0.60
Total Fees: $60.60
Construction Value: $300.00
Total Fees: $60.60
Total Receipts: $0.00
If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection
fee is $50.00, which must be paid in advance before calling for another inspection.
This Permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the application herefor in strict compliance with all
ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any plans, drawings, statements or specifications that may have been submitted to
and approved by the proper municipal authorities. This Permit may be revoked at any time if the work is not done in compliance with such ordinances or if the plans are changed without
authorization. A further condition upon which this permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the
ordinances and regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes responsibility for work done
by his agents, servants or employees.
(I SPECTOR) BY:
In consideration of the issuance to m 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 responisibility for all work done by either
myself, my agent, servants or employes.
�✓ (Contractor or Builder) BY:
r'r: ' i 1 C { ?i7: tmr . . f g rr'r� t � tt. n�rr r t: i ,,1
RFC Lv1.1 ,J1fUJ Uf }L }'ll.,d,IJi 005503 LImi RG'F. zod.ou
DATE:X 3
OWNER'S N
ADDRESS:
MIAMI SHUKES VILLAGE
Paint Color ApprQvaliA hit:gement
* * * * * * * * * * * * * * * * * * * * * * * * ** ** olr* 0 % * * * * : * * * * * * * * * * * * * * * * * * * * * * **
ADDRESS OF SITE: : :.. -_ :•• -. •
CONTRACTOR & LICENSE (if applicable) • 01 . 1 - & .
COMPANY NAME: PHONE:
********************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
All Elements on the site must be lis-ed and indicate the color to be painted.
Walls
Fascia
Drip Cap/Dri. Edge
Soffit
Roof
Flower Bins
Shutters
Awnings
Chimney fi
Doors and door jams
Garage Doors
Railings
Fences
Decorative Metal
APPROVED:
03
...
• .: •••
•
_
All brick (simulated or regular)
Stucco Banding
Any other stucco features
Accessory'Buildings
Other
06
0
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. I authorize the above -named contractor, if applicable, to
do the work stated. Furthermore , the paint colors will be as per the attached
sample
373
S ignature of Owner Date Signature of Contractor Date
*********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
WHEN PAINTING IS FINISHED,
CALL FOR FINAL INSPECTION
7/0
Building Official ial Date 4/23/01
OWNER BUILDER DISrI .9SUL FA..TEMENT
: : :•: :. • :• • • .. •
_ • • ... ..I. / ,L// N j)i tJTVJ being the legal property owner, for the property 7
Located at: /c0702 /v6' 9r/P /&z' ' alam, J%,k
Legally described as ,
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),,nd I have real and understand the following disclosure
Statement, which entitles me td work as my own contractor, I further understand that I as the owner
must appear in person to complete all applicaticns.
State law requires construction to be done by licensed contractors. You have applied for a permit under an
exemption to that 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 o a farm out - building. You may also build or improve a
commercial building at a cost of $25,000.00 or less The building must be for your own use and occupancy. It
may not be built for sale or lease. If you sell or lea ;e a building you have built yourself within one year after the
construction is completed, the law will presume that you built it for sale or lease, which is a violation of this
exemption. You may not hire an unlicensed person as your contractor. It is your responsibility to make sure
that 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 1 hat you must deduct F.I.C.A. and with - holding tax and
provide workers' compensation for that employ ee, all as prescribed by law. Your construction must comply
with all applicable laws, ordinances, building codes and zoning regulations.
Proof of ownership provided ( )
BY E TA. c aui to
Produced PL. 2 76r7i 11 - 0
Owner
• • • ..
• • • • •'• • • • ••• • VILLAGE OF ISII3MI NJufRES
BUILDING DFARTMENI
• •; . • • •
• •
DISCLOSURE STATEMENT
initial of reviewing clerk. The foregoing instrument
Was acknowledged before me this / 3 day of , 20 0 3
•
who is personally known to me or who has
as identification and who did take an oath.
Notary
Pu OFFlCIALNOTARY SEAL
1P @� GLADYS J VILLAR
i
'
COMMISSION NUMBER
411'3 Q DD091094
` , MY COMMISSION EXPIRES
F OF FL MAR. 1,2006
Date /// :5 7 Job Address /4 Otk. �'� �: Tax Folio
Legal Description /!)1, ,il6" 56 0s4 orically Designated: Yes
Owner/Lessee / Tenant :ice aS ' I /►QS, Master Permit #
Owner's Address 1 � ° '�� , M 14,4 ! s /= is / .(4, Phone 711 ° e /5 y7 7 7
Contracting Co. ,P;
Qualifier SS# Phone
State # M s • . : Ins. Co.
Architect/Engineer
Bonding Company
ti
Mortgagor
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL - TG PAVING FENCE SIGN
WORK DESCRIPTION v e1,41„ A,—N/A/4 J
TAATI "AvIAITA( 63 (.- 6A ecl g as' , l - �oA_rr Looq
Square Ft Estimated Cost (value)
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY 3EFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I
certify that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
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. Furthermore, I authorize the above -named contractor to do the work stated.
� ) % / /
zA44 - ., 144 4 7 ,
7
.
e of er � 6r Condo President Date Stgnatnrr fContra of or Owner- Builder Date
Signature a� /
Notary as to Owner and/or Condo President Date
My Commission Expires:
FEES: PERMIT RADON
PERMIT APPLICATION FOR MIAMI SHORES VILLAC
APPROVED:
Zoning Building
Mechanical Plumbing
,`P COY Pei OFFICIAL NOTARY SEAL
O
(::- SANDRA M MONTIEL
2 * C OMMISSION NUMBER
i s .i Q CC401261
- q ' MY COMMISSION EXP.
� OF FkP AUG, 17 196
C.C.F. , {�
Address
Mt
No
No • as to Contractor or Owner - Builder
My Commission Expires:
Electrical
Date
((
Y BOND
TOTAL DUE
/
114
5 ..
• • .•. • s e 0
• COUNTY-WIDE LAND SURVeo i d.
LAND SURVEYORS. PLANNED.: • • • •'•
P.O. BOX 823271 SOUTH FLORIDA,. • FL. 33082 •3271 • (302) 71 .• 2. -0766
• . "
•
• .
• • : • . . "•
. :• • •
•• .•
. .00 • • •
‘064 -7/0A. SKF 70/ /Vo7 7c5c'4L.E'
LEGAL DESCRIPTION
Lot 3 and the East 15 feet of Lot 2 in Block 2 of WATERSEDGE,
according to the plat thereof, as recorded in Plat Book 9 at
Page 141 of the Public Records of Miami -Dade County, Florida.
SURVEYORS NOTES:
1). Legal description provided by client.
2). Only record plat easements are shown.
3). Right of way information obtained from record plat.
4? LW Fedara1 Flood plc X a rc1 G903 la-&L revised 3 -2 -94.
5). Benchmark used- Dade County Benchamrk # B -62.
6). Elevations are referenced to National Geodetic Vertical Datum
1929 Adjustment (NGVD29).
Boundary, Improvements & Elevation Survey
gt*vy FORS Juan & Ruthe Santos 1022 NE 91 Terr. Miami Shores, F1. 33138
CERTIFICATE NOTE: " NOT VALID UNLESS SEALED WITH AN EMBOSSED SURVEYORS SEAL."
1 HEREBY • =RTIFY THAT THE SURVEY' REPRESENTED HEREON COMPLIES KITH THE
MINIMUM T:CHNICAL STANDARDS ADOPTED BY THE FLORIDA BOARD OF SURVEYORS AND
MAPPERS I CHAPTER 62G 17 -6, PLORIDA ADMINISTRATIVE CODE, PURSURANT TO.
SECTION 4 .'27, Florida Statutes.
JOSEPH L. MARTIN
PROFESSIONAL LANG SURVEYOR * 4368
STATE OF FLORIDA
REVISIONS
DRAWN BY
)91
BY
Ea./ PG.
DATE
100
Z004 - /o2Z
SCALE DATE
/ " = 20' 2-7-04-
DS
•
.. .•-
• •.. . .••
• • • •
• - � • •
• • •
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• • ••• .
•• •. • . • • •••
• . . •.•••• .
• .•• : •
• • • • • 8 . •
0s. • .
• 7./11 1 9l 7E'a .
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PIPE
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PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address , A • .. i Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant 1r £ /7w c 1/IAJ % D3 Master Permit # ;79372
Owner's Address PhoneK , l aS ,) - 4 q,',/ 9
Contracting Co.X '0 1 A) 11.- V' Address
Qualifier `1 SS# Phone
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one):
WORK DESCRIPTION
ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
/& 7a- P-1- e, or
Square Ft. Estimated Cost (value)
i
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO 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.)
Application is hereby made to obtain a permit to do work and installation, as indicated above, and on the attached addendum (if applicable). I certify that all work
will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required for ELECTRICAL
PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNERS 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. Furthermore, I authorize the above -named contractor to do the work stated.
Signature of owner and/or Condo President Date
gnature of _ on
s to Contractor or Owner - Builder Date
Notary as to Owner and/or Condo President Date No
My Commission Expires: My ommission Expir s: OFFICIAL NOT Y S
FEES: PERMIT 'O . RADON C.C.F. 4' NOTARY BOND
APPROVED:
Zoning
Mechanical
Electrical
r
0(2
or or Owner rl er \ p ate
�Ow . — '11.5. 74 - s - o4 o y
Z?
GLADYS J VILLAR
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. CC7141113
MY COMMISSION EXP. MAR. 121232
TOTAL DUE
Plumbing Structural Engineer