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PAINTPERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date 0/�I7 Job Address 275 it t VIII— Tax Folio Legal Description '� BL.iy / Tenant BiD i6 4 _A * Owne1's Address 1 dU • - ga4 Historically Designated: Yes Master Permit # Phone No 75 ` 3 7 0 3 Contracting Co. e) a C9 t Address Qualifier \ C L 4 s vL Municipal # G'" 1 State # Architect/Engineer Bonding Company Mortgagor Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN . 4 - - ee-& \ ^"A WORK DESCRIPTION evs »lam C ( •e Square Ft. LI WARNING TO OWNE 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. 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. Suture of owner and/or Condo President Date FEES: PERMIT 140 RADON APPROVED: Zoning Building Mechanical Date C.C.F. Y PU OFFICIAL NOTARY UAL 1P B pi SANDRA M MONTIEL 2 . COMMISSION NUMBER r „� CC40126 SS # Phone m ) 8 ' 5 7-N ( Competency # C9 O G c2 1 `( Ins. Co. Address Address Address Estimated Cost (value) 0 .2-\ 133 (t ofctor or O r- Builder g c -6 E.-z Notary as to Contractor or Owner - Builder Date My Commission Expires: � _ 1 NOTARY Electrical BOND Date TOTAL DUE Plumbing Engineering BUILDING ELECTRICAL PLUMBING Owner of Building Architect Contractor or Builder Legal Lot Bl. Description Address of Building MIAMI SHORES VILLAGE, FLORIDA PERMIT N9 3677 Work to be performed under this Permit Subdi- vision DATE Contractor's License No. r chi tray t9 to v Gia ar • ,f Value of Project author.z44i in Amt. of Permit 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. Signed• By INSPECTOR In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regula- tions 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, servant or employee. CONTRACTOR OR BUILDER BY AUTHORITY BUILDING ELECTRICAL PLUMBING Owner of/ Building Architect Contractor or Builder f Legal Lot Bl. Description Address of 3uilding CONTRACTOR OR BUILDER MIAMI SHORES VILLAGE, FLORIDA PERMIT N9 3677 Work to be performed under this Permit Subdi- vision Value of Project DATE 194_ Contractor's License No. Amt. of Permit • 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 fora 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. Signed. By INSPECTOR In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regula- ions pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores 'illage. In accepting this permit I assume responsibility for all work done by either myself, my agent, servant or employee. - A 1 , BY 'AUTHORITY MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the build- ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of the work. Owner's Name and Address Registered Architect and /or Engineer Name and address of licensed contractor Location and legal description of lot to be built on: Lot Block Subdivision Street and Number where work is to be done State be done and ur _�Q _ -y po - building floors) 4,� and who, being of the above des therein by him s Permit No ss. me fir duly sworn, upon oa ribed c struction, that he has ted arcs' ue..' ./c3 ! Date__ de P / be sent to Council Approved Date Date , 19 No.__ ( _1! Street_ and for no other purpose. New Building emodeling Addition Repairs No. of Stories To be constructed of Kind of foundation Roof Covering Estimated Total cost of improvements $ d 6_,_ 0 Amount of Permit $ Zone cubage required _Plan Cubage Distance to next nearest building Size of Building Lot Maximum live load to be borne by each floor I hereby submit all the plans and specifications for said buildin All noti es with reference to the building and its construction may The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement, and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such ublic notice or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, pn work to be pe ormed under this permit, as are licensed by Miami Shores Village. Remarks ( Signed) _ STATE OF FLORIDA, COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, peared to me well known, es and says that he is the_ ly read the foregoing application, and that he did sign the same, and that all facts 5 %ead, Sworn to and Subscribed before me. . - h'„ _ to Disapproved u, ding I Spector " %/ My Commission Expires / PLANNING OARD DATE Chairman/ Member Member Member Member Member Notary Public, State of Florida Disapproved Date NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from the Planning Board. A re- inspection fee of $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and /or workmanship. Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regula- tions of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of the work. Owner's Name and Address L AJ-- C Registered Architect and /or Engineer Name and address of licensed contractor Location and legal description of lot to be built on: Lot_ Block—_—_ Subdivisio Street and Number where work is to be done State„,litork to be done and purpose of building (by floors) New Building_______________ ________ Remodeling____________ —__ Addition__ To be constructed of___________ —_ Kind of foundation Estimated Total cost of improvements $______ Zone cubage required Distance to next nearest building Maximum live load to be borne by each floor I hereby submit all the plans and specifications for said building. All notices with reference to the building and its be sent to The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement, and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspects on the site e), ork such public notice or notices as are required by the Act. The undersigned agrees to employ only such subs ctors, on wo to = be performed under this permit, as are licensed by Miami Shores Village. `l 1, Remarks (Signed) STATE OF FLORIDA, COUNTY OF DADE. MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMIT Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that be is the of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. 4 Permit No.__ Disapproved _________ (Signed) Date Date Building Inspector PLANNING BOARD (-) Date----- - - - -_- / No. Street - -__- —_ aI ) _ / '1 �)) _. 4� / - _-- _Amount of Permit $ —__flan Cubage__ __________ Size of Building Lot _and for no other purpose. Repairs No. of Stories______________ Roof Covering Read, Sworn to and Subscribed before me. Notary Public, State of Florida My Commission Expires DATE construction may Chairman Member _ Member Member Member Member Council Approved____ Date Disapproved __Date NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from , 1 the Planning Board. A re- inspection fee of $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and /or workmanship. PROPERTY OWNER New Construction Name 15 l>b ,t(' 4 J (� 3 -v B L�� Enclosure Address al.- i -/)' E' Pjt1y `G Alteration Exterior FIomeTelephone (35- 6'3 3 Business Telephone &)5... 756- 5 pp 2 / / Fax 305 -757— /534 TYPE OF MANAGEMENT (✓ ) New Construction Enclosure Alteration Exterior Repair Alteration Interior Demolish Relocation of Structure Shell Only Foundation Only Add'l Attachment Other Add'l Detachment Other Step 1. • • • • • ••• • • • • • • • • • • • • • • • • • • ••••••• •••• ••• • • • • • • • • Mastet Jermit No. • •••• • ••• • • PERMIT APPLICATION te • : SubsidiacY Permit No. • • • INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village: Complete the attached permit application VII& Sign4f y e Progerty owner and qualifier. Both signatures must be notarized. Please print or type to allow for a more accurate poses :illy o ;y4n4w?licadon. If joofing work will 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. Job Address: 76 /0 G� ' 9 / '� / I/�✓j'1i` 0 k 3 3 ( 3 City State Zip Address Folio Number description of Work Or t5 S Cteti.v,., } eo,-• Lot Block Subdivision PB PG Zoning Linear Feet Current Use of Property Square Feet Units Floors Proposed Use of Property slue of Work 2 �j v Bldg Value Tenant Information T x Assessed/Appraised Value Flood Zone Base Floor Elev. PERMIT TYPE (✓ ) Building Electrical Mechanical Plumbing LPGX Roofing Fence Other Apt. PERMIT CHANGE (✓ ) Chg. Contractor Renewal Revision Extension Supplement Reinspection ARCHITECT Name License No. Address Telephone Fax ENGINEER Name License No. Address Telephone Fax CONTRACTOR Name License No. Address Telephone Fax Qualifier Name Page 2 IMPORTANT NOTICES 1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECCIV,PLC,YQUR VALIDATED PEQMLT AND PERMIT CARD. Applying for a permit does not grant the right to begin construction. HOURS OF CONSTRUCTION are limited te:• Month, throng' 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 holidays. 2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris. 3. STREETS AND NEIGHBORING PROPERTIES SHALL BE ICE ' An ledm DT 3NU l • $I2IS. 4. SWALES MUST BE PROTECTED FROM BEING DAMAGII BY En1IP N3' QR 'EtlIQL I ES, AND MAY NOT BE USED FOR STORAGE. A bond is required for work in or near the street/sidewalk. ° 0 0 0 • ° s o • • • ° o o ° 0 0 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 your 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. STATE OF FLORI 'i " S igns o f Owner C/7 20 ® ''rint Name V day of A e- Sworn to and subscribed before me this ,4093 . Sign. of Notary Public - State o SEAL: X0 FI� oR� I+ , c01 w- ° Personally known `l � OR, Produced Identification Type of Identification Produced: • •• •• • • 0 00 •0 o 0 0 o •• 0 0 0 0 O 0 0 •s• 0 0 0 O 0 0 • 0 0 0 0 000 0 0 s 0 000 0 0 PERMIT APPLICATION STATE OF FLORIDA, COUNTY OF MIAMI -DADE Signature of Contractor / Qualifier YY) tc� -e.2 S L �u tV't— Print Name L� ,,��jj Sworn to and subscribed before me this / day of o 3G03 . • blic - 4 6 S- 9 1 1 - 1 . - 3 . 1' r 1 4� DAMES NOTARY PUBLIC STATE OF FLORIDA COMM • N NO. CCU _MYCO} r'ISSION EXP. MAY 1i 003 / Si, *', " ', eofNo ta ry SEAL: Personally known OR, Produced Identification Type of Identification Produced: ELECTRICAL TYPE Minimum Fee QTY TYPE Dryer QTY "•.'Y :'I: •Qupet, Appliance Q 'mil.: Service Repair ()T1 A/C Central 1 -3 Ton - Heating Strips, each Fan •' • • • • eunn Wall Service, Temporary Paint Booth A/C Central 4 -7 Ton Fire Pump Outlet, Switch - Piping, Flammable Liquid Signs A/C Central 8 -15 Ton Fixture - Fluorescent Process/Pressure Piping Oven Space Heater (kw) A/C Central 16-20 Ton Pressure Vessel 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 Tl'1'I: Minimum Fee QTY. TYPE Condensate Drain QTY. TYPE Generator QTY. '1'1"1'1. Refrigeration, Tons QTV. A/C Central, Tons QTY. Cooling Tower - Heating Strips, each Vent Hood, Cost A/C Wall/Win. 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 Pump and Abandon Bath Fan - Vented, # Fireplaces, Number of Pressure Vessel Gas - Appliance PLUMBING TY 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 3 •• •• • • • • • •• • • • • • • • • • • • • • • •• • • • • • • • • • • • • • • • • • • • ••••••• •••• ••• • • • ••• PERMIT APPLICATION • •• • • • • INSTRUCTIONS: Please indicate the type of irk being and quantity(ies) in the space provided below. • •• • ••• • RECEIVED AND REVIEWED BY: DATE: SECTION BY DATE Zoning K.. ' 0-1, P 3 J Electrical Mechanical Plumbing Fire Public Works Structural Building Official -4"t49 Page 4 OFFICE USE ONLY CHECKLIST U OWNER - BUILDER FORM (Attach) m FIRE DEPARTMENT APPROVAL (Commercial / multi - family) CONCURRENCY (New Construction) UI OTHER (Specify & Attach) PERMIT FEES $3.00 per page (Scanning Fee) Miami Shores Village Bond o • e • 000 • ••• • • • • • • • L IMPACT FEE (New Construction) UJ OTHER (Specify & Attach) $ Metropolitan Dade County (C.C.F.) $ Le-3i (sq.ft. = x/1000 x0.60) Inspector State Educational Fund $ State DCA (Radon) $ Code Enforcement Fine Zoning Review Notary ISSUING OFFICIAL REVIEWED AND PREPARED BY: DATE: (¢.01 /sq.ft.) • ••• 0 0 0 0. 0 0 0 0 0 0 0 000 0 0 • • 0 0 0 0 ••• • • PROtF O OW ITP (Attach) 00 ••• •• 0 • 0 00 0 • • • • • 0 0 • HRS /.DERM PE$CNRL: • o (Septisd Serer; e 0 0 0 00 (¢.005 /sq.ft.) 0 o 0 $ /-2 v ,4 /f'pc i y Y / I VO PERMIT APPLICATION LI CONDO ASSOCIATION APPROVAL (Attach) ® BPR APPROVAL (Restaurants) LI CONTRACTOR REGISTRATION (On File) TOTAL $ 0 CONDITION OF Revised July 2001 10050 N.E. 2ND AVE., MIAMI SHORES, FL a (305) 795 -2207 FAX (305) 756 -8972 o http : / /www.miamishoresvillage.com Miami Shores Village 10050 NE 2nd Avenue Phone: 305- 795 -2204 Permit Number: BP2003 -420 Printed: 3/14/2003 Applicant: CAROL BLUM Owner: BLUM CAROL JOB ADDRESS: 275 NE 92 ST Contractor Local Phone: Parcel # 1132060133570 This Permit is granted to the cc ordinances pertaining thereto and and approved by the proper muni■ authorization. A further condition ordinances and regulations pertai by his agents, servants or employ Signed: In consideration of the issuance with the plans, drawings, statemE myself, my agent, servants or err Signed: �� Building Permit Contractor's Address: Page 1 of 1 Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOT 14 & W15FT OF LOT 15 BLK 26 LOT SIZE Fees: Description Amount FEE2003 -1564 Building Fee $120.00 FEE2003 -1565 Code Enforcement Fine $100.00 FEE2003 -1566 CCF $1.80 Total Fees: $221.80 Total Fees: $221.80 Total Receipts: $0.00 Permit Status: APPROVED Permit Expiration: 9/10/2003 Construction Value: $2,500.00 Work: EXTERIOR PAITING AS PER AGREEMENT If there is no permit packane accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection fee is $50.00, which must BAYSHORE PAINTERS OF MIAMI, INC. 425 N E 93RD ST MIAMI SHORES, FL 33138 PH. 305 - 756 -8861 FOR rs) DATE PAY THE O O DER j /)/) , c � ( �'+ I ) � ORDER OF � / (/ J o =✓' � \ cp . 16,1v w1.,0\.r-e� �� a 1A.R. aot ltrt First Union National Bank r J Miami, Florida Rif 067006432 000 2 2 20'i 1:06 70064 3 21: 20900001S4f.7 2 ?no 2220 63- 643/670 BRANCH 00901 3 - /?- 3 $ �� gj0 ? /o DOLLARS 0 s t3'°"°" Date Type Insp'n Permit No. Approved Correction Re- Insp'n Fee MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Requ t / Time /✓1C, Name '''� Address 2 _ i C,� . �- Company Phone # For Inspector: g — - Name & Date MIAMI SHORES VILLAGE Paint ColokApp*aL'•apd Agreement DATE: OWNER'S NAME: 1.0 • .T' Q- . ADDRESS: it/, C— r,c7 .. • xampl 1 g APPROVED: • • • ... PHONE: • . p,,,, � ,, 23/3? *********** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * ** A DDRESS OF SITE: �� -: • : l� _ • CONTRACTOR & LICENS'(it • COMPANY NAME: PHONE: ********************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** All Elements on the site must be l ted and indicate the color to be painted. Walls 5A- n Pt mou ts- -� A00 , Fascia .t2t-ct, � Drip Cap/Drip Edge Soffit S- \ Roof Flower Bins Shutters Awnings Chimney Doors and door jams Garage Doors Railings Fences Decorative Metal All brick (simulated or regular) Stucco Banding Any other stucco features c:' AA, Accessory Buildings Other N OAAA) 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 state Furthermore , tJae paint colors will be as per the attached nature f Owner Date Signature of Contractor Date **,********************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** WHEN PAINTING IS FINISHED, CALL FOR FINAL INSPECTION Building Official Date 4/23/01