500 NE 93 St (5)M I A M I•DADE
PRODUCT CONTROL NOTICE OF ACCEPTANCE
DAB Door Company, Inc.
12195 NW 98 Avenue
Hialeah Gardens ,FL 33018
The expense of such testing will be incurred by the manufacturer.
APPROVED: 08 /02/2001
•
\\s045000 I pc2000\ \templates \notice acceptance cover page.dot
Internet mail address: postmaster @buildingcodconline.com
MIAMI - DADE COUNTY. FLORIDA
METRO -DADE FLAGLER BUILDING
BUILDING CODE COMPLIANCE OFFICE
METRO - DADE FLAGLER BUILDING
140 WEST FLAGLER STREET. SUITE 1603
MIAMI. FLORIDA 33130 -1563
(305) 375 -2901 FAX (305) 375 -2908
CONTRACTOR LICENSING SECTION
(305) 375 -2527 FAX (305) 375 -2558
CONTRACTOR ENFORCEMENT 1IVISION
(305) 375.2966 FAX (305) 375-290X
I'RODUCI' CONTROL DIVISION
(305) 375 -2902 FAX (305) 372.6339
Your application for Notice of Acceptance (NOA) of:
Sectional Residential Garage Door
under Chapter 8 of the Code of Miami -Dade County governing the use of Alternate Materials and Types of
Construction, and completely described herein, has been recommended for acceptance by the Miami-Dade
County Building Code Compliance Office (BCCO) under the conditions specified herein.
This NOA shall not be valid after the expiration date stated below. BCCO reserves the right to secure this
product or material at any time from a jobsite or manufacturer's plant for quality control testing. If this
product or material fails to perform in the approved manner, BCCO may revoke, modify, or suspend the
use of such product or material immediately. BCCO reserves the right to revoke this approval, if it is
determined by BCCO that this product or material fails to meet the requirements of the South Florida
Building Code.
ACCEPTANCE NO.: 01 0620.11
EXPIRES: 08/14/2006 Raul Rodriguez
Chief Product Control Division
THIS IS TIIE COVERSHEET, SEE ADDITIONAL PAGES FOR SPECIFIC AND GENERAL
CONDITIONS
BUILDING CODE & PRODUCT REVIEW COMMITTEE
This application for Product Approval has been reviewed by the BCCO and approved by the Building
Code and Product Review Committee to be used in Miami -Dade County, Florida under the conditions set
forth above.
Francisco 1. Quintana, R.A.
Director
Miami -Dade County
Building Code Compliance Office
Homepage: http : / /www.buildingcodeonlinc.com
DAB Door Company, Inc. ACCEPTANCE NO: 01- 0620.11
APPROVED:. AUG 0 2 2001
EXPIRES: 08/14/2006
NOTICE OF ACCEPTANCE: SPECIFIC CONDITIONS
1. SCOPE
1.1 This renews the Notice of Acceptance No. 98- 0901.10 which was issued on 10/22/98. It approves a Sectional
Steel Door as described in Section 2 of this Notice of Acceptance. And it is designed to comply with the So rth
Florida Building Code, 1994 Edition for Miami -Dade County (SFBCC) for the locations where the pressure
requirements, as determined by SFBC Chapter 23, do not exceed the design pressure rating values indicated in
the approved drawings.
2. PRODUCT DESCRIPTION
2.1 The DAB 9'wide Sectional Door and its components shall be constructed in strict compliance with the
following documents: Drawing No. 98 -01, titled "Sectional Residential Garage Door" prepared by AI- Farooq
Corporation, dated 01/30/98 with latest revision on 08/24/98, Sheet 1 to 2 of 2. It bears the Miami -Dade Count
Product Control Approval stamp with the Notice of Acceptance number and approval date by Miami -Dade
Product Control Division. These documents shall hereinafter be referred to as the approved drawings.
3. LIMITATIONS
3.1 Units with dimensions equal to or smaller than those shown on the approved drawings shall qualify under this
approval.
3.2 This approval requires the manufacturer to do testing of all coils used to fabricate door panels under this Notice
of Acceptance. A minimum of 2 specimcns shall be cut from each coil and tensile tested according to ASTM E
8 by a Dade County Approved Laboratory selected and paid by the manufacturer. Every 3 months, 4 times a
year the manufacturer shall mail to this office a copy of the Test Reports with confirmation that the specimens
were selected from coils at the manufacturer's production facilities. And a notarized statement from the
manufacturer that only coils with a yield strength of 34,000 PSI or more shall be used to make door panels for
Dadc County under this Noticc of Acceptance.
4. INSTALLATION
4.1 The Sectional Door and its components shall be constructed in strict compliance with the approved drawings.
4.2 The installation of this door does not require a Hurricane Protection System
5. LABELING
5.1 Each door shall bear a permanent label with the manufacturer's name or logo, city, state and the following
statement: "Miami -Dade County Product Control Approved
6. BUILDING PERMIT
6.1 Building Permit shall be accompanied by copies oldie following:
6.1.1 This Noticc of Acceptance, including two topics of the approved drawings as identified in Section 2.
6.1.2 Any other document required by the Building Official or the SFBC n order to properly evaluate the
installation of this system.
Candido Font, PE, Sr. Product Control Examiner
Product Control Division
DAB Door Company, Inc. ACCEPTANCE NO: 01- 0620.11
APPROVED: AUG 0 2 2001
EXPIRES: 08/14/200
NOTICE OF ACCEPTANCE STANDARD CONDITIONS
1. Renewal of this Acceptance (approval) shall be considered after a renewal application has been filed and the origina
submitted documentation, including test - supporting data, engineering documents, are no older than eight (8) yecrs.
2. Any and all approved products shall be permanently labeled with the manufacturer's name, city, state, and the
following statement: "Miami -Dade County Product Control Approved ", or as specifically stated in the specific
conditions of this Acceptance.
3. Renewals of Acceptance will not be considered if:
a) There has been a change in the South Florida Building Code affecting the evaluation of this product and the product
is not in compliance with the code changes;
b) The product is no longer the same product (identical) as the one originally approved;
c) If the Acceptance holder has not complied with all the requirements of this acceptance, including the correct
installation of the product;
d) The engineer who originally prepared, signed and sealed the required documentation initially submitted is no longer
practicing the engineering profession.
4. Any revision or change in the materials, use, and /or manufacture of the product or process shall automatically be
cause for termination of this Acceptance, unless prior written approval has been requested (through the filing of a
revision application with appropriate fee) and granted by this office.
5. Any of the following shall also be grounds for removal of this Acceptance:
a) Unsatisfactory performance of this product or process.
b) Misuse of this Acccptancc as an endorsement of any product, for sales, advertising or any other purpose.
6. The Notice of Acceptance number preceded by the words Miami -Dade County, Florida, and followed by the
expiration date may be displayed in advertising literature. If any portion of the Notice of Acccptancc is displayed,
then it shall be done in its entirety.
7. A copy of this Acceptance as well as approved drawings and other documents, where it applies, shall be provided to
the user by the manufacturer or its distributors and shall be available for inspection at the job site at all time. The
engineer need not reseal the copies.
8. Failure to comply with any section of this Acccptancc shall be cause for termination and removal of Acceptance.
9. This Notice of Acccptancc consists of pages I, 2 and this last page 3.
Candido Font, PE, Sr. Product Control Examiner
Product Control Division
END OF TIIIS ACCEPTANCE
-3-
000A NOcHT
CONSKTS OF
6' -6'
2 SECTIONS 16'
2 SECTIONS 21"
6' -9'
1 SECTION 16'
3 SECTIONS 21'
r
4 SECTIONS 21"
-
7 • -.1
-
-
7' -6'
5 sECn0Ns 15'
-
7' -9'
4 SECTIONS 16"
1 SECTION 21'
e'
3 SECTIONS 18'
2 SECTIONS 21"
8' -3'
2 SECTIONS 1e'
3 SECTIONS 21'
8' -6'
1 SEcnoN 16"
• SEcnoNS 21'
8' -9'
s sECnO•S 21'
-
9'
6 ,SECnoNS 16'
-
9' -3'
5 SECTIONS 18'
1 SECTION 21"
9' -6'
• srcnoNS 18'
2 SECTIONS 21'
a' -9'
3 SECTIONS te'
3 SECTIONS 21'
10'
3. SECTIONS 1e'
4 SECTIONS 21'
10' -3'
1 iECnON 16'
3 SECTIONS 21'
10' -6'
6 SECTIONS I1'
-
10' -9'
6 •YECTIONS 18'
1 SECTION 21'
11'
3 SECTIONS 16'
2 SECTIONS 21'
11' -3"
4 SECTIONS I5'
3 sECnoKS 21'
11' -6'
3 SECTIONS 18'
4 SECTIONS 21"
11' -9"
2 SECnONS 18'
5 SECTIONS 21'
12'
I SECTIONS 16'
6 SECTIONS 21'
12' -3'
7 SECTIONS 21'
-
17' -6'
6 SECTIONS 16'
2 SECTIONS 71'
12' -9"
5 SECTIONS 16"
3 SECTIONS 21'
13'
4 SECTIONS 16'
4 SECTIONS 21'
13' -3'
3 SECTIONS 18"
5 SECTIONS 21'
13' -6'
2 SECTIONS 15'
6 SECTIONS 21'
13' -9'
1 SECTION 18'
7 SECTIONS 21"
1 4
6 SECTIONS 21'
-
1 4' -3"
6 SECTIONS I6"
3 SECTIONS 21'
14' -6'
5 .SECTIONS 14'
4 SECTIONS 21'
1 4' -9'
4 SECTIONS 1e'
5 SECTIONS 21'
13'
3 SECTIONS 16'
6 SECTIONS 21
13' -3`
2 SECTIONS 18'
7 SECTIONS 21'
15' -6"
1 SECTION 18'
6 SECTIONS 21'
15' - 9'
9 SECTIONS 21•
-
1 6'
6 SECTIONS 18'
4 SECTIONS 21'
GENERAL. NOTES
I. THIS STRUCTURE IS DESIGNED AS PER THE SOUTH FLORIDA
BUILDING CODE 1994 EDITION FOR 0ADE COUNTY. ALSO FOR WINO
LOADS AS PER ASCE 7 -88 USING CORRESPONDING LOADS.
2. ANCHORS SHALL BE AS USTED. SPACED AS SHOWN ON DETAILS.
ANCHOR EMBEDMENT TO BASE MATERIAL SHALL BE BEYOND WALL /
DRESSING OR STUCCO.
3. ALL BOLTS. NUTS AND WASHERS SHALL BE ZINC PLATED CARBON STEEL •
4. ANCHORING OR LOADING CONOITIONS OTHER THAN THOSE SHOWN IN /
THESE DETAILS ARE NOT PART or THIS APPROVAL.
OPTIONAL STOP MOULDING
BY DOOR INSTALLER -
STEEL TRACK BRACKET FASTENED
TO WOOD JAMB WITH
/ ONE 5/16" X 1 -5/8' LAG SCREW
SOUTHERN PINE
0.55 S.G.
/ 13 GA. STEEL TRACK BRACKETS
SEE SHEET 2 FOR SPACING
- 3/4 MAX. I
/ 14 GA. CALV. STEEL TRACK
FASTENED TO TRACK PLATES
W/ 1/4 -20 x 5/8" TRUSS H0.
SLOTTED M.S. & LOCK NUT
OUTSIDE HANDLE
r
/ 7/16" PUSHNUT
INSTALLED ON ROLLER SHAFT
CENTER STILE
If!
fi 14 X 1/2' SMS
4 PER HINGE
T
LOCK BAR GUIDES
INSTALLED ON ENO STILE
LOCK BAR
ENGAGES IN TRACK
ON EACH SIDE OF DOOR
OUTSIDE KEYED LOCK '
LOCK BAR LOCKING SHOWN 7 X 7 CALV. AIRCRAFT TYPE
CABLE & NICO -PRESS SLEEVE
W/ MIN. 5 TO 1 SAFETY FACTOR
1/2" X 1 -3/4" X 1/16 VERT. ALUM TUBE
-CLUED 70 PANEL AND SECURED TO
END STILE WITH 3/16' POP RIVETS 0 12' 0.C.
1
14 GA. CALV. STEEL
ENO RLLEF1 /
W/ (4) 1 14 X 1/2' SMS
2/ DOOR
1 - 7/8" X 2 -5/8" X 18
CENTER STILE
/.
14 CA. GALV. STEEL
CENTER HINGE
SECTION 8 -
SPRING LOADED SLIDE COLT LOCK (BOTH 510ES)
FASTENED w/ (4) tf 14 X 5/8 S.M.S.
5/8" MIN. LOCK ENGAGEMENT CONFORMS TO
SFBC .3603.2 REGARDING GARAGE 000RS /
CA. STEEL /
/ 14 X 5/8' S.M.S.
2/ HINGE
r POP RIVETS
ROLLER HIItGE
-4
_3/4 X 2 -1/2 X 18 CA. STEEL .
END STILE
/ •
�a
I
3/4' MAX.
CENTER STILE
ti
OPTIONAL VENT
MAXIMUM OPENING AREA
80 S0. IN.
MAX. 000R WIOTH
INSIDE ELEVATION
RAISED PANEL EMBOSSED 000R
J
5/16' HILTI SLEEVE ANCHORS OR EOUAL
1 -1/2" MIN. EMBED INTO MASONRY /
f PER BRACKET
Engr. OR. HUMAYOUN FAROOO
STRUCTURES
FLA. PE / 16557
t�1h1
1(=
200
- _AUG_02 001
W
S
DAB DOOR MODEL 824
MAX. SIZE 9' —O" WIDE X 16 -0" HIGH I
DESIGN PRESSURE RATING = + 53.0 PSF
— 60.0 PSF
THIS DRAWING IS PROPERTY OF DAB 000RS INC.
COPYRIGHT 1998. TRADEMARK PROTECTED
DO NOT REPRODUCE WITHOUT WRITTEN CONSENT.
PATENT PROTECTED
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drawing no.
98 -01
(sheet 1 of 2
DOOR
HEIGHT
• SECTION.
HEIGHTS
BRACKET PLACEMENTS
1ST
2ND
3RD
4TH
5TH
A
81 -r
82
83
84
85
86
• 87
88
6' -0"
18"
18"
18
1
r
11 -3/4"
23"
34"
45" -
56"
67"
-
6' -6"
21"
18"
1 8
21'
N/A
1"
11 -3/4"
23"
34"
45"
56"
67"
- •
7' -0"
21"
21"
21"
21"
N/A
1"
11 -3/4
23"
- 34'
45"
56"
67"
78 -1/4"
7' -6"
18"
18"
18"
18"
18"
1'
11-3/
23"
34"
45"
56"
67'
78-1/4"
' "
8 -0
21 " "
18
18
18"
21"
1'
11-3/4"
23"
34"
45"
56"
67"
78-1/4"
•- SECTIONS ARE NUMBERED STARTING AT THE BOTTOM
HORIZONTAL REINFORCEMENT
1/2" X 1 -3/4" X 1/16" ALUM TUBE
CLUED TO PANEL ANO FASTENED TO
VERTICAL STILES WITH
(2) 3/16" POP RIVETS
I ,1
HORIZONTAL REINFORCEMENT
1/2" X 1 -3/4" X 1/16" ALUM TUBE
CUT TO MISS RIB
GLUED TO ANEL AND FASTENED TO
VERTICAL STILES WITH
(2) 3/16" POP RIVETS
i
' 21" PANEL
'SECTION A —A
POP RIVETS 7 SUDE F STEEL ASTENED TO BRACKET
W/ 5/16 -18 X 3/4" HEX HEAD -
M. SCREWS & NUTS.
12 GA. CALV. STEEL
TOP ROLLER BRACKET (DOUBLE)
FASTENED w/ (6) 1 14 X 5/8" S.M.S.
Fil== 18 GA. X 2-1/4" X 2" GALV. STEEL U.BAR
REINFORCING TRUES 0 CENTER OF TOP SECTION
TRUSS FASTENED TO ALL VERTICAL STILES
W/ TWO if 14 X 5/8" 5.M.5.
7/16" DIA X 3 -3/4" ROLLER SHAFT
OPTIONAL
EPS- EXPANDED POLYSTYRENE INSULATION
BY APACHE PRODUCTS CO. -
DENSITY - 1.07 PCF
N.O.A. 9B- 0409.03 '
14 CA. CALV. STEEL
ROLLER HINGES FASTENED
W/ (4) / 14 X 5/8' SMS
FLAPS BENT OVER PANEL
.i
1/2" PUNCHED HOLES
0 4" 0.C.
MIN. 24 CA ROLL FORMED S1ttL PANEL `O4)29`)
DRAWING OUAUTY G -40
MIN. YIELD STRENGTH = 34 KS1
WITH PRIMER AND BAKED -ON
POLYSTER PAINTED TOP COAT
APPUED TO BOTH SIDES OF STEEL
18 CA. X 2 -1/4" X 2" CALV. STEEL U.BAR
REINFORCING TRUSS 0 BOTTOM OF BOTTOM SECTION
TRUSS FASTENED TO ALL VERTICAL STILES
W/ TWO / 14 X 5/8" S.M.S.
12 GA. CALV. STEEL '
BOTTOM BRACKET FASTENED
W/ (4) / 14 X 5/8" SMS
BOTTOM SEAL
.039 ALUM PLATE
WITH (2) 1/8" X 1" S.M.S.
AND RUBBER WEATHERSTRIPPING
' 24 CA STEEL PANEL
FOR DOORS MORE THAN 8 FT. HIGH USE ADDITIONAL TOP BRACKETS AT 10" 0.C.
5/16" X 1 -5/8" LAC SCREWS INTO WOOD OR
5/16" SLEEVE ANCHORS WITH 1 EMBED INTO MASONRY
3 PER BRACKET,
/ END STILE
THIS DRAWING IS PROPERTY OF DAB DOOR. I'IC.
COPYRIGHT 1998. TRADEMARK PROTECTED
DO NOT REPRODUCE WITHOUT WRITTEN CONSENT.
PATENT PENO!NG
2 -I/2" X 4 -1/4" X 13 CA. STEEL PLATES
WELDED TO 1 -1/2" x 1 -1/2" X 14 C.A. ANGLE
1-
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W
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0
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TRACK CONFIGURATION
CAST ALUM. •
......../CABLE DRUM
RIZ. TRACK LENGTH = OPENING HEIGHT PLUS 12" '
14 GA. GALV. STEEL TRACK
HORIZ. TRACK SUPPORT • -
WOOD FRAME BUILDINGS
' STUD WALLS OR DOOR OPENING SHALL BE FRAMED SOUO
BY NOT LESS THAN (3) 2X4 PRESSURE TREATED GRADE 2
'OR BETTER WOOD STUDS.
STUD WALLS TO BE CONT. FROM FOOTING TO TIE BEAM.
WOOD BUCK CONNECTION TO MASONRY
• TRACK SHALL BE SECURED WITH TRACK BRACKETS TO
PRESSURE TREATED 2X6 W000 JAMBS WHICH SHALL
• BE ANCHORED TO GROUTED REINFORCED MASONRY
BLOCK WALL OR CONC. COLUMN W/ 1 /4" TAPCONS
WITH 1 -3/4" EMBED AND A SPACING OF 10" 0.C.
OR 3/8" DIA. HILT1 SLEEVE ANCHORS, 1 -3/4' MIN.
/ EMBED AND A SPACING OF 12" 0.C.
THE BLOCK WALL CELLS SHALL BE GROUT Ruxo AND
• REINFORCED WITH FOUR / 5 BARS EXTENDING INTO
FOOTING ANO INTO TIE BEAMS, ALL BARS SHALL BE
• CONTINUOUS FROM TIE BEAMS TO FOOTING.
• PREPARATION OF JAMBS BY OTHERS
2" X 3 -1/2" X 12 C.A. TRACK BRACKETS
2 -3/16" HIGH
CONNECTED TO TRACK WITH ONE
1/4" BOLTS & NUTS.
Engr: OR. HUMAYOUN FAR000
STRUCTURES
FLA. PE 1 16557
MAY 6 2001
AM.C7cD ! C.C''�'ii ::'v ":ITl1 TIIE
nT:: Fi C ::c" + 'uii ;N.r.; CODE
P._E_AUG. 2001_ ._..
BUII.4it.'7. CTTftCE
ACCTPTA';CE '71. Olt —OG ZO. 1 /
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drawing no.
98 -01
(sheet 2 of 2 j
CONTRACTOR
`�i
Name C octio wore_ Co t . Iw
License No. qq 1x105 3o_ yaq5.-Cxoq
Address 33 1f 3r
YYLcl yt-c- ) FL 33138
Telephone (3051 7 S 7 - N1 /3 F a x ( )757 _. fills'
I
Qualifier Name
mil 0 ci.
PROPERTY OWNER
Name B .4 4, T„,✓e pithison
Address 5.-co NE tot!) sr
rytca 'iu $horns, F( 33135
Home Telephone /g�1 ...76-4 — r g03
ll
o £
N
Business Telephone
Fax NONE
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
✓
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'l Attachment
Other
Add'I Detachment
Other
INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
Step 1.
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
Job Address:
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Soo NM civic ST
Address
Apt.
Folio Number it- - 3.06° 0144- 11 10
Lot q Block S
Subdivision PB PG
Current Use of Property keSiCedLeL
Proposed Use of Property I 6\ -41--e
Tenant Information
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
N/R
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
PERMIT CHANGE (✓ )
ARCHITECT / 0 4
Name
License No.
Address
Telephone
Fax
PERMIT APPLICATION
Master Permit No. ' ��
Subsidiary Permit No. a °`
flka.v t�, Shores Fc 33138
City State , Zip
Description of Work & Q ( - U oof-
Zoning
Square Feet
Value of Work
S o0
63 h
Linear Feet ` "
Tax Assessed/Appraised Value
Units
A,A
Floors
Bldg Value N/A
Flood Zone Base Floor Elev.
ENGINEER AVA
Name
License No.
Address
Telephone
Fax
Page 2
INIPORTANT NOTICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF 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 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 KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT 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 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 FLORIDA, COUNTY OF MIAMI -DADE STATE OF FL
Sigftature of Owner
Print Name ,�t
Sworn to and subscribed before me this 31 day of � ,
aD0,
Signature of Notary
SEAL:
he = Stile ofFfonda
P i, JENNIFER JOHNSON
i° . MY COMMISSION # CC 903127
''For EXPIRES: Jan 18, 2004
t� °
7.8063- Fla. Notary Service 8 Bonding Co.
Personally known OR, Produced Identification
Type of Identification Produced: i'L AL £613" '0/ &o °7? f
Signature of Contractor / Qualifier
Print Name
/ 5T
Sworn to and subscribed before me this day of e l .
-
Signature of Nota
e PN, JENNIFER JOHNSON
MY COMMISSION # CC 903127
v tof f>° EXPIRES: Jan 18, 2004
1 Fla. Notary SeMce 8 Bonding Co.
Personally known X OR, Produced Identification
Type of Identification Produced:
SEAL:
bfura
PERMIT APPLICATION
A, COUNTY OF MIAMI -DADE
e of Florida
ELECTRICAL
TYPE
Minimum Fee
QTY.
TYPE
Dryer
QTY.
'TYPE
Outlet, Appliance
QTY.
TYPE
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.
Tl'PE
Condensate Drain
QTY.
TviE
Generator
QTl'.
TYPE
Refrigeration, Tons
QTY.
A/C Central, Tons
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
Supply, AC Well
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
Temporary Toilet
PLUMBING
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 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
Page 4
OFFICE USE ONLY
CHECKLIST
❑ 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
❑ PROOF OF OWNERSHIP
(Attach)
❑ HRS / DERM APPROVAL
(Septic / Sewer)
❑ IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
PERNIIT FEES
SECTION
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
BY
DATE
Metropolitan Dade County (C.C.F.) $ r K7 0 (sq.ft. = x/1000
x 0.60)
Inspector State Educational Fund $ (¢.005 / sq.ft.)
State DCA (Radon) $ (¢.01 /sq.ft.)
Code Enforcement Fine $
Zoning Review
REVIEWED AND PREPARED BY:
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
TOTAL $
ISSUING OFFICIAL
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
BUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of -
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
Lot
MIAMI SHORES VILLAGE, FLORIDA
❑ PERMIT N° 15874
❑ Work to be performed under this Permit
f
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 o if the plans are changed without authorization. A further condition upon which this permit is
granted is the understanding that the contractor or builder name 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 • .. x 4, . BY , 1
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 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, servant or employee.
CONTRACTOR OR BUIL}jIER
Value of
Project $ Amt, of
r II Permit r• $
Subdi-
vision
DATE ° •
AUTHORITY
195
Contractor's
License No
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 Budding Ordinance of Miami
Shores Village, Florida, and all provisions of the Laws cf the Satu of Florida, all ordinances of Mianu Shores Village and all rules and
regulations of the Building 1 vit. iun 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.
1 19 e/1
No ....- Street
Re Architect end /or Engineer .- ' . -v-
, � - . d
- - :•-' -
_ - - - _ _ - -• . `'
Name and address of licensed contractor .._ �' z ? � ^`E' _.� .. . �' ` i..._, - / _ , - .
Location and legal description of lot to be built on: �.
I
-7 _ Subdivision P '—
Lot_ ._. ___._ �........_.._.._... .._
Street and Number where w is to be done. - -- • - -. yle_ `� ` (
art 5. ( L <
State work to be done and purpose of building (by floors) — ._
and for no other purpose.
N e w Building._..! _._ - - . Remodeling_. _ -_ _.... Addition. -.- • -_ -_ -- ._... ._.. Repairs..._ ..... _ .. No.of Stogies
To be constructed of . - _.. Kind of foundation._ .. Roof Covering_
Estimated T -. ,tal cost of improvements $ - l" 1 /7! Amount c< Permit $
Zone cubage required —..... ---- __ -.__ _Plan Cubes... -- .._ -- - •-
Distance to next nearest bustling.. - - • -- . Size of Building Lot
Maximum live load to be borne by each floor
hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
The underoiyaed applicant for this building permit does hereby certify That be understands and accepts his obligations as an employer
of labor under the Florida Workunen's Compensation Act, being Section 5988, Compiled General Laws of Florida, Permanent Snppirn ant.
and h u compled with the 11trovi<ions thereof, and will require similar conroliance from all contractors or sub- contractors employed by hin,
in the wok to be p: rf nmed under this pernat: and will post or cause to be posted for inspection an the site of the work such public notih e
or notices as are requited L•y the At The under agrees to employ only such subcontr.:etors, on k to be perfnrnn d :u,der this
permit as are heensed by Miami Shores Village. s ? `
Remarks.. .......... - (Signed) ... .�.
STATE OF FLORTDA. j„,;..
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
and who, beings by me first drily sworn, upon oath depotes and says that he is the
of th abov. de scribed , nstrucllon, tl.. t re has carefully read the foregoing application, and that he did sign the same, and that all tact
therein by him stated are true.
Permit No .1 Date .__.. - 3_ T Read, Sworn to and Subscribed before me.
(Signed) - - .
Bw
te_.
or
PLANNING BOARD
Notary Public. State of Florida
My Com:nission Expires
_...._. _ to me well known,
DATE
Chairman Member
Member ....._ ._ _•.. - -- _ ___..._._.. Member
Member .- _.. Member
Council Approved - _. -Date Disapproved ••. Date
NOTE: A charge of $1.00 will be made for malting corrections or changes to this application after approval his been obtained from
the Planning Board.
A re-imecnon fee of $1.00 will be charged when such re- inspection is mane necessary by improper notice for impaction or faLity
matenals a worlonanship.
°
(,,O U._'l (: _ �i l r)r.
y
•
•
•
,• I
•
.2.(;,
t;
V
4-1
eeviae_ 7-4
CLIENT
CONTRACTOR f + L-Fra9G4 wr d< SAn
PROJECT _ Real.dence — KOO )fLE. 9Ird At.
LOCATIO �' ` W
REPORTED TO
Lab. No.
Sample No.
Specified Strength
Mix
Brand of Cement
Fine Aggregate
Coarse Aggregate
Slump in ins.
Gals. Water to
Admixture
Cylinder Made
Da•Tested
7 DayTested
28 Day-Tested
WINGERTER LABORATORIES, INC.
Engineer's I kaboratory and Inspection Service
� i60 N. W. 71st STREET
MIAMI 38, FLORIDA
REPORT OF TESTS OF CONCRETE CYLINDERS
I. . Sethi 11j (' p NiAnri Fla,
O cc, 771.0 0
0.36397-lag
340$k
Bldg. Permit No 157811
City of 1li*!L Snores
REPORT No
ORDER No 2 9103
• . y
11,11 •. •
Sack
Batch
Condition of Cylinder
Dia, el Cylinder
Area is sq. ins.
Total Load in lbs.
Unit Load per sq. in.
Wt. of Cylinder, Lbs.
Age of Specimen
Type of Break
Cylinder Received
Curing Labs
T,,j t)irlg Cn, 3)ih() !J
39855
558
2000 p.s.1
. 5 beg
trot given
Seminole
•
6.5M
not given
11 11
Good
6.o
28.27
27.5
3 -14-54
Labs allied
3-3-54
3- 10.54
39856
559
. in 28 eayps
5 bag
not given
Seminole
ti
6.5"
not givetrl
II II
39857
560
•5 bag
not given
Seminole
6..5•
not given
tt u
INIORMA ?ION IVRNIUN[D •Y LABORATORY
Good 4pd
6.0 1 6.0
2 8.27 ' 28.27
52,500. . 53,500
27 7 92
. 5 27 .5
aa„ys 7 dills
3 -1154 5.1754
704 t 20 74 mds ty
3-3.54
3- 10-54
3-344
310414
Copies Issued to
2 - I.E.Sohilling Coe
1 r. R. 7, O •ok
1 - Mr. E. C. Knox
As a mutual protection to clients: the public and ourselves, all reptult
publication of statements cooclusloop pr exttiacts from or
V- River Dz'ivet Yie Fla
REMARKS: Strength Requirement
Information fur
urnished by otir instrmotoms4illH
Weather condition
Concrete furnished by
Test cylinders made at ..
Ticket No. vitae
2 Cubic Yard
Air Content
r.E.Sehi1].ing w e.
Central Plant Utz.
10,35 A#4.
Truck No.
Time Batched 91t2 A.M.
NGER ER LABORATORIES; INC.
.,4
Co
t4 submitted as the a gfldentinl .property of crots, find autborfsation for
rdgerdipp Is I ield,pending our 'written approval; .,
Slum
4
dor
Lab. No.
Sample No.
Specified Strength
Mix
Brand of Cement
Fine Aggregate
Coarse Aggregate
Slump in ins.
Gels. Water to Sac
Batch
Admixture
Condition of Cylinder
Die. of Cylinder
Area in sq. ins.
Total Load in Ibs.
Unit Loed per sq. in.
Wt. of Cylinder, Lbs.
Age of Specimen
Type of Break
Cylinder Received
Curing Lab.
Cylinder Made
3 Day- Tested
7 Day- Tested
28 Day- Tested
Copies lasued
2 B. Schilling Co.
1 -Mr. Ii. F. Cook
1.W. E. C. Knox
WINGERTER, LABORATORIES,
Engineer's 'Laboratory and Inspection Service
660 N. W. 71st STREET
MIAMI 38, FLORIDA
REPORT OF TESTS OF CONCRETE CYLINDERS
T. E. Schilling Co. ±iatud,, forida
F. L. I`raaier Son ✓ oa 1740 ✓ (eit..c_
Ttesidsnae
CLIENT
CONTRACTOR
PROJECT
LOCATION 500 1. L. 93rd Street
/forth footing midway between) E. do R. footing
Air Content
INC.
o 6906 -0M
3 -20.44
Bldg. Permit No 15784
REPORT No
235
ORDER No 291o3
I. I. Schilling Co., 3460 N.; W. 1. ?ivsr lyrive, Miami, Flory± da
REPORTED TO
39118
448
2000 p.5.1.
Not given .
Not given
Seminole
5"
trot given
• N
Good
6.0"
28.27
77p000
2724
28.0
28 days
f #3
2_22-54 -
Lab. cured
2 -20-54
3 -2o-54
39119
449
In 20 day.
Not given
lot giver
e inole
5"
Not ;riven
>t N
I ION IY /NI
Good
6.0"
28.27
81,500
2882
28.0
28 days
#3
2 -22 -54
No g 2°
2 -20-54
3 -20-54
39120
450
Not given
Mot given
Seminole
1t
5"
at liven
• •
N[D ■V LA /O /ATO /V
Cood
6.0"
28.27
�7�000
28.0
28 days
#3
2 -22 -54
Humidity 9
2 -20-54
3 -20
REMARKS: Strength Requirement
Information furnished by our inspector =Y iu1
Weather condition clear
Concrete furnished by T. X. Schilling Co.
Gentlm►1 PrI nt Nix
Test cylinders made at 8 , 115 a. .
Ticket No. 86626 Truck No. 125
11 Cubic Yard Time Batched 1142 A.M.
W 4GERT R LABORATORIES, INC.
iti
Cone
Coos Shear
Shear
4
Split
As a mutual protection to clients, the public and ourselves. all reports are submitted at the confidential property of eats, and authorization for
publication of statements, conclusions or extracts from or regarding our reports is reserved ndin g our written approval. .
Pe g
CLIENT
CONTRACTOR " •
» varier ex . SOn
Eeeidence 500 N.
LOCATION Tie 3eela 'S. :!. c of Bldg.
PROJECT
REPORTED TO 1. J'•SCliwii) 4n z CU•
Lab. No.
Sample No.
Specified Strength
Mix
Brand of Cement
Fine Aggregate
Coarse Aggregate
Slump in in..
- A58
20)C
5 bag
Not given
t ninole
•
5"
Not given
n
3*54
3 -31-54
1 ,
39859
5
in 2` dA4s
5 bag
Not given
Seminole
6.5"
Not given
r1
Good Good
6.o" 6.0'
2S.27 28.27
71,500 71,000
2,529 2,617
26.0 28.0
28 'days 28 days
3-4 -54 3-4 -54
Lab. cured .. 700 + 2
ION rUNMI•
3-3-54
3 -31 -54
39860
563
5 bag
Not given
Seminole
"
6.5"
Not given
" •
3-3-54
1110 .r - LR.Oa11TORY
6 0ood
28.27
28.0'
284471
3-11 -514
Gals. Water to Sack
Batch
Admixture
Condition of Cylinder
Die. of Cylinder
Area in .q. WI.
Total Load in lb..
Unit Load per .q. in.
Wt. of Cylinder, Lbs.
Age of Specimen
Type of Break
Cylinder Received
Fiel
Curing Lebo
Cylinder Mad.
3 Da•T.sted
7 Da•Te.ted
28 DeyT.sted
Copies Issued to
WINGERTER LABORATORIES, INC.
Engineer'sI.aboratory and Inspection Service
660 N. W. 71.t STREET
MIAMI 38, FLORIDA
REPORT OF TESTS OF CONCRETE CYLINDERS
T. a.`. cI illtr r`o•, M.acri,F1$
2 - ::(hill.ng Co,
1 T' r. . ?,..F. Cook
1 - r.I.C. Knox
?46L N.W. W. River Drivt;, Miami
Jrco MA) 3 t(
REMARKS: Strength Requirement 11O t'^ifrly
Our Y speotor AIR
C lea. r 744
Information furnished by
Weather condition
Concrete furnished by
Test cylinders made at
Ticket No..,g 7122
Cubic Yard
Air Content
Florida
Bldg. Permit No. 157'4
Mi Shores
REPORT No
0- 37721, —Ii i
3 -31-54
270
ORDER No 291.3
r 11i it Co.
^ontral lent "Ix
Truck NO. 109-
Time Batched 922240. p__
ABORATORIES, INC.
Co .
Coos Sear
Shear
Sit
As a mutual protection to clients. the public and ourselves. all reports are submitted as the confidential property clients, and authorization for
publication of statements, conclusions or extracts kohl or regarding our reports is reserved pending our written approval:
< f ao ; t
#w + »« Q
p e « ¥£
Ls.;
:yma ®ate
f r :w
• : t m
w a.&
± s
R
z «�
z
OWNER'S NAME P
PRESENT ADDRESS L
LICENSE NO. P
PHON' NO.
1
JOB LOCATION (ST. OR AVE.) L
LOT B
BLOCK S
SUBDIVISION
BUILDING PERMIT AND INSPECTION RECORD -MIAMI SHORES VILLAGE
INSPECTIONS
DATE
BY1
RE- INSPECT
BY
RE- INSPECT
BY
FOUNDATION
•
I 1 -
��y �'1
P
TEMPORARY SERVICE
i 4 ? `' b
ice"'"` �. -
S
BEAMS & LINTELS
3-. Qys
•I„42._
SEWER /1 S? 944
..37)94.4
s
FRAMING
SOLAR HEATER
5
GAS
$
$
INSPECTIONS
FINAL
1?` r'
�.
BY
RE- INSPECT
BY
ROUGHING
CLEAN -UP
�
1A4.0.4
•'
j i
GAS
_. '
CONTRACTOR ' .t ., - "a
PHONE
��/
PERMIT NO. / 3- / q 0 DATE Pa 17d s'l
FEE $ /l
NEW BLDG. I ALTERATION I ADDITION
REPAIRS
SPECIAL PERMITS
PERMIT NO.
DATE
FEE
TEMPORARY SERVICE
i 4 ? `' b
ice"'"` �. -
S
SEPTIC TANK
$
SEWER /1 S? 944
..37)94.4
s
$
SOLAR HEATER
5
GAS
$
$
INSPECTIONS
DATE
BY
RE- INSPECT
BY
RE- INSPECT
BY
ROUGHING
- % y a. 1
�
1A4.0.4
2- 1+ ?-
j i
GAS
J ;/,.. _ '
)i %.
SEWER
SEPTIC TANK
SOLAR HEATER
FIXTURES
` )
CONTRACTOR 3 ' - = L ry.e{' . .
PHONE
JJ °
PERMIT NO. ! (n I DATE ��iii•
/,y
., % . -i
FEE $ :yam --
NEW BLDG. ALTERATION 1 ADDITION
REPAIRS
SPECIAL PERMITS
PERMIT NO.
DATE
FEE
TEMPORARY SERVICE
i 4 ? `' b
ice"'"` �. -
� >i ' •
H. W. HEATER CONN.
$
RANGE CONN.
$
MOTORS
$
FIXTURES
$
$
INSPECTIONS
DATE
BY
RE- INSPECT
BY
RE- INSPECT
BY
TEMP. SERVICE
Yv)C Ci
2- 1+ ?-
j i
ROUGHING
J ;/,.. _ '
)i %.
H. W. HEATER CONN
RANGE CONN.
FIXTURES & FINAL
` )
•
BUILDING INSPECTIONS
PLUMBING PERMITS & INSPECTIONS
gLECTRICAJ, PERMITS & INSPECTIONS
APPROVAL TO POWER CO. FOR SERVICE DATE
BY
N9 1966
CERTIFICATE OF OCCUPANCY
MIAMI SHORES VILLAGE, FLORIDA
BUILDING DIVISION
Miami Shores Village, Fla ,
ii-z4
Owner, Agent or Tenant of Building
Lot Block Subdivision r �'1 + •�- a ��-
Street Address
BUIL ING DIVISION
Approved use by occupancy �','� •.!Jt.+�,• , s
Remarks-
This Certificate of Occupancy is issued to the above named .c.` : JLi
for building at above named location only upon the express provision that the applicant will
abide by and comply with all conditions of Ordinances Nos. 92, 93, 94 and 97, known as the
Zoning, Electrical, Plumbing and Building Ordinances of Miami Shores Village pertaining to
the erection, construction, alteration or remodeling of buildings or structures.
1
ii 3S . v
Date
Type Insp'q
Permit No.
Name
Address
Company
Phone # JU
For Inspec tor C�
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Re- Insp'n Fee
)Time
o n -- D 6 -)
>
ame & Date
Approved
Correction
i
i tul t