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955 NE 92 St (7)For Inspecto Approved Correction Re- Insp'n Fee MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date Time /p Type lnsp'n Permit No. 6P9063 1 3i 0. Name Address 9SS NE .) Company 9614, ] \q W3. Phone # Name & Date 3Z -H C $ Value of Work For this Permit Building Department BUILDING PERMIT APPLICATION FBC 2001 Permit Type (circle): ' ■. u lding Owner's Name (Fee Simple Titleholder) Stories Number of: Bays Type of Work: ❑Addition ❑Alteration c Describe Work: 1', Miami Shores Village Electrical 191 Plumbing Mechanical Roofing SxS�t , -il Is Building Historically Designated YES NO Contractor's Company Name 1(Q,4 l eqti t11-1 ' ` I Contractor's Address 1 + f - V City I: I 6 State �✓ Qualifier t A L ,` 1 t y M , ( 3, 1/ Families :New 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Permit NoP g.✓" J 13 - Master Permit No. Phone # Owner's Address ; () 4 g' 1 . r o (' Cit jM Ory irA >P State ?1,, Zip f� 1 Tenant/Lessee Name Phone # .316 ' r /(�'f`) q ` 0 1 Job Address (where the work is being done) CISS 1 U -/ City Miami Shores Village County Miami -Dade Zip . -.J.9 1 Phone # Y D) 43'"1-16"1 Zip , 1gt9 Architect/Engineer's Name (if applicable) ■ Phone # Architect/Engineer's Address City State Zip Square Footage Of Work: 1 in Ei 1 Bedrooms Baths ❑ Repair/Replace ❑ Demolition * * * *. * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Coun ty Escrow Fee $ 2° Permit Fee $ 0 . 0" Notary $ Education/Training Fee $ Tech $ Scanning $ Radon $ Code Enforcement $ Bond $ Struct. $ Minus Plans Check Fee $ Total Fee Now Due $ i - (Continued 20 opposite side) POt rC C - I Bonding City ding Company's Name (if applicable) 's Address Mortgage Lender's Name (if applicable) Mortgage Lender's Address City The fore o day of who is :hc7/7/03 J Owner or Agent • State 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 'di occurs seven (7) days after the . buildin inspection wilLnot b 'ppro ed and a reinspection fee , 71 be charged. 8 permit is issued. In the absence of such posted. notice, the / f © Signature • ent was a o le ged befo me 9lis ,by ; Sh o me or who has produced As identification and who did take an oath. Signature The fore , day of who is NOTARY PUB Sign:. ** Printt:: 'into` :` y Commission �4t41gsion #DD21526'r ''' ••_ Expires: May 16,00 My Commission Expires: s ;�i•.. , ;le►O�,' Bonded ThN (Certificate of Competency Holder) °F ` Atlantic Bonding Co Inc State Certificate or Registration No. Certificate of Competency No. APPLICATION APPROVED BY: •/./ • Contractor• o in s ent was acknowled 20 d3, by Zip ' ed before m this of , e or who has produced as identification and who did take an oath. '' balm ' ec?" s',AY P, �r.t _ p Commission #DD215 i • ;'� •. . oP *�4I*t*l3o � Its * * * * * * ** Plans Examiner Engineer Zoning Wi MIAMI SHORES VILLAGE Paint Color Approval and Agreement DATE: `v 13 V� OWNER'S N ►' i 1 Mill • ` PHONE: W , (W ADDRESS: I0 ). 6cc )t, e.co DC_ i 1 ***** * ** * * * * * * * * * * * * * * * * * * * * * * * * **** * * * * * * * * * * * * * * * * * * ** ** YQS X31.30 ADDRESS OF SITE: a55 ape- rQLf UUQYt o CONTRACTOR & LICENSE (if applicable) CO RSoo 1 GceG COMPANY NAME: /)i Sty i ov Corp. PHONE: 3os -(p3c - `j%31 ***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * ** All Elements on the site must be listed and 'ndicate the color to be painted. Walls W t � lJD'I"I,IS -9'0 Fascia (Ai frki os- t zoz Drip Cap/Drip Edge /3.� Soffit A/4- Roof Flower Bins Shutters Awnings i Chimney Al 4 Doors and door jams 6 \ Q Garage Doors /' Railings Ai A Fences Decorative Metal All brick (simulated or regular) /U/t Stucco Banding /U Any other stucco features ,f) 4 Accessory Buildings / A Other APPROVED: s s N ti �111 ru : Cd lAaAl 7:1 cn , 4rdot D 3 OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be don /in compliance with all applicable laws regulating construct and zoning. uthorize the above -named contractor, if applicable, to do the or stated. Fu , = rmore the paint colors will be as per the attached 15_tq_0 / 'T - r/ - a re of Owner Date igna a of Contrac ate ****************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** WHEN PAINTING IS FINISHED, CALL FOR FINAL INSPECTION Building Official Date 4/23/01 MIAli'II SHORES VILLAGE Paint Color Approval and Agreement DATE: q— 1-0 OWNER'S NAME: ebb 2 Ccts \-‘, ti a PHONE: Ds- 9301 ADDRESS: i 1 E d d r,`eid 11e. b i rb r I's kin d **** ****************************** * * * * * * * *W * * * * * * * * * * * * * * * * * * * * ** ADDRESS OF SITE: ?C'S AIE fa ‘v- skew f- *apt: S/i,5 s €5 Lori( CONTRACTOR & LICENSE (if �a applicable) 6,2 65 ci ©6 COMPANY NAME: r5 J� a + Uv 5 A:4 t co o. PHONE: 3aS- �'3 i - 95 s7 **** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * ** * * * * * * * * * * * * * * * * * * * * * * ** All Elements on the site must be listed and indicate the color to be painted. Walls Meal 11 V c 2O a (: - ( Fascia k■h, i Drip Cap/Drip Edge /1)4 Soffit Roof Flower Bins Shutters I Awnings J P Chimney k1 r Doors and door jams i) . Garage Doors fJ m Railings ;) A- P k Fences Decorative Metal Gofrk - \ e_ All brick (simulated or regular) AI k Stucco Banding k) -' r Any other stucco features /U A Accessory Buildings Ai A- Other /U N 0 0 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 samples. Signature of Owner Date Signature of C tra r Date *********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED: WHEN PAINTING IS FINISHED, CALL FOR FINAL INSPECTION ✓�� , G � 3 nd -}.. 4/23/01 Building Offici'al ate c 'Reg u e3 0 0 moonlight iami Shores Village 0 10050 NE 2nd Avenue Phone: 305 - 795 -2204 O .-.D Applicant: Owner: ACH R/r 063100277 Printed: 3/12/2002 Contractor Local Phone: Parcel # 1132060060050 Job Address: 955 NE 92 ST Fees: ©( FEE2002 -1485 Building Permit Application Fe$60.00 $1.20 $3.80 $65.00 FEE2002 -1486 FEE2002 -1487 Permit Status: Approved Permit Expiration: 9/8/2002 Construction Value: Work: EXTERIOR PAINTING AS PER AGREEMENT (OWNER BUILDER PERMIT) 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. Deborah A. Castillo or Mario E. Castillo DEBORAH CASTILLO Description Amount CCF Miscellaneous Total Fees: Date 3/7/ Pay io the /7 ^ l ��J�✓?� ` f f i / / 1 $ Orderof 1� / Dollars BankofAmerica, Bank of America Advantage 3or I:06 300004 71: 00 L L986 2 380 LP 4 260 Building Permit Permit Number: BP2002 -517 Address: Cellular: CASTILLO DEBORAH Legal Description: GOLDEN GATE PK AMD ie equipment or device described in the application herefor in strict compliance with all 4260 vith any plans, drawings, statements or specifications that may have been submitted to not done in compliance with such ordinances or if the plans are changed without 63 -4/630 FL tor or builder named above assumes the responsibility for a thorough knowledge of the 1035 gs or in the statements or specifications and that he assumes responsibility for work done SEATREASUAE wrn BY: BY: $2,000.00 Page 1 of 1 PB 7 -54 LOTS 5 & 6 LOT SIZE 100.000 X 140 OR Total Fees: $65.00 Total Receipts: $0.00 compliance with all ordinances and regulations pertaining thereto and in strict conformity :s Village. In accepting this permit'l assume responisibility for all work done by either MIAMI SHORES VILLAGE Paint Color Approval and Agreement DATE: 3/7/o� OWNER'S NAME: � /O li 044 /e) PHONE: , fard ,»',,'2/ ADDRESS: /a// ,79/ J - mo i-, - G 3/5 / ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ADDRESS OF SITE:,, Axe-- CONTRACTOR & LICENSE (if applicable) COMPANY NAME: PHONE: ********************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** All Elements on the site must be listed and indicate the color to be painted. Walls Fascia Drip Cap/Drip Edge Soffit 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 Accessory Buildings Other 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 sam Signature of Owner Date * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED: 3/7// Building Official Date 1 % ; f2. ,_995 0 r 0 z Signature of Contractor Date **** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** WHEN PAINTING IS FINISHED, CALL FOR FINAL INSPECTION 4/23/01 • PROPERTY OWNER Name Al L /� ,c! / ' /' Address - _ s r- /W0 ,s-io ' fit- Home Telephone ?o j -s j7362 Business Telephong,,„v F,, 42p / Fax ?CV e f -,s TYPE OF MANAGEMENT (✓ ) New Construction Enclosure Alteration Exterior Repair Alteration Interior Demolish Relocation of Structure Shell Only Foundation Only Add'I Attachment Other Add'l Detachment Other INSTRUCTIONS - The follovi steps must be taken to obtain a permit from the Miami Shores Village: Step 1. 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. 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 Folio Number Lot Block Subdivision Current Use of Property Proposed Use of Property ie PERMIT TYPE (✓ ) Building Electrical Mechanical Plumbing LPGX Roofing Fence Other Address Apt. PERMIT CHANGE (✓ ) Chg. Contractor Renewal Revision Extension Supplement Reinspection ARCHITECT Name License No. Address Telephone Fax Master Permit No. Subsidiary Permit No. fr5P c)-(¢6) c ' / Ore City (('�� Statte Description of Wort&` .Aai e �' PERMIT APPLICATION Zip PB PG Zoning Linear Feet ��54a G Square Feet 2 D 0 Units Floors G✓e ?4, Value of Work Bldg Value Tenant Information T "71 /i9G6srgi -jai/ Tax Assessed/Appraised Value / Flood Zone Base Floor Elev. ENGINEER Name License No. Address Telephone Fax CONTRACTOR Name License No. Address Telephone Fax Qualifier Name Page 2 IMPORTANT NOTICES I. 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 PROTEC'T'ED 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. i 6. PORTABLE TOILETS for a construction site require a separate permit. t 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 iti 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 Commencemi nt 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 ORIDA, CO OF IAMI -DADE STATE OF FLORIDA, COUNTY dF MIAMI -DADE Signature of Owner Signature of Contractor / Qualifier //4 Print Name �f Sw to nd subscribed before me this < day of/ ' /" Print Name Sworn to and subscribed before me this day of Signature of Notary Public - State of Florida' I I PERMIT APPLICATION 0PRV P SEAL: O ,fe, ANGELA M BECKER 1 SEAL: 0 COMMISSION NUMBER " 86697 OF F1. NOV. i5, ;'uri? Personally known OR, Produced tdenu Ica Ion °` " Personally known OR, Produced Identification Type of Identification ( ' > Type of Identification Produced: t ELECTRICAL TYPE Minimum Fee QTY. TYPE Dryer QTY. TYPE. Outlet, Appliance QTY. TYPE: Service Repair QTY. A/C Central 1 -3 Ton Heating Strips, each Fan Outlet, 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 Violatkas 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. TYPE: Refrigeration, Tons QTY. A/C Central, Tons Q . Q . Y . 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 TYPE A/C Condensate QTY. TYPE Drains, Roof QTY . Miscellaneous Fixture QTY i Soakage Pit Q . Q . Y . 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 t PERMIT APPLICATION INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below. RECEIVED AND REVIEWED BY: DATE: SECTION BY DATE Zonin: /r�_'L 0711 Electrical Mechanical Plumbing Fire Public Works Structural Building Official ..--jf 1 LZt.s 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 Inspector State Educational Fund $ State DCA (Radon) $ Code Enforcement Fine Zoning Review ❑ PROOF OF OWNERSHIP (Attach) ❑ HRS / DERM APPROVAL (Septic / Sewer) ❑ IMPACT FEE (New Construction) O OTHER (Specify & Attach) PERMIT FEES $ Co -0 Metropolitan Dade County (C.C.F.) $ 1 0 (sq.ft. = x/1000 x ¢.60) $ (¢.005 /sq.ft.) (¢.01 /sq.ft.) REVIEWED AND PREPARED BY: PERMIT APPLICATION ❑ CONDO ASSOCIATION APPROVAL (Attach) ❑ BPR APPROVAL (Restaurants) ❑ CONTRACTOR REGISTRATION (On File) ISSUING OFFICIAL 1 fc 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 PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date; /n ) 7 Job Address (Ass N Q. eta 5 T r eta Tax Folio Legal Description Historically Designated: Yes 1 Owner/Lessee / Tenant c(Y! 7 e f I LA iAn S's wio A 5 D II Master Permit # i te ) S73 Owner's Address 55 NC— q l 5 et-t Phone Pi ci D 70.2 — 799O,m Contracting Co. N D N (y / Address Qualifier SS# Phone State # Municipal # Competency # Ins. Co. Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING G .ELE_CTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN CJ� WORK DESCRIPTION - R C O ( / f - 4 rC t a \ /- ?7 Square Ft. 4 1 0 0 O ep P. 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. OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable la =ws regulating construction and zoning. Furthermore, I authorize the above -n d contractor to do e work stated. orgnature of owner and/or Condo President Date 'Signature of Con Notary as to Owner and/or Condo President Date My Commission Expires: APPROVED: Zoning Mechanical Building Plumbing Estimated Cost (value) 40.00.0D ctor or Owner- Builder Notary as to Contractor or Owner - Built, -r _ _ _ Date My Commission Expi es; j sczy if r�07A;77 (n Electrical ,J 9 : d61) FEES: PERMIT 4 70. RADON C.C.F. v‘ NOTARY U. BOND f) • TOTAL DUE Date Engineering