MECHANICALMIAMI SHORES VILLAGE
BUILDING DEPART ENT
305- 795 -2204
Building Inspection Requ
Date .1 I S�
Type Insp'n Itl / '1
Permit No. 1.4 c 1 "1 3q
14ey )? 6 cD
Company Lie Y ' f 12-e /-r
323-0SKK
Name
Address
Phone #
Inspection Date
L l
Approved ❑
Correction ❑
Re- Insp'n Fee ❑
BUILDING
PERMIT APPLICATION
FBC 2001
$ Value of Work For this Permit c
use
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
x'10
kkumA D rye, I - IL/51-1c ( j
Square Footage Of Work:
Contractor's Address 4 (0 0 0 St*)
City inn iGUin I State Zip 331 CC
Qualifier 1),e.Ar) S V , S IvYI
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Type of Work: ❑Addition ❑Alteration New L] Repair/Replace ❑ Demolition
Describe Work: C(/ a,n -O.4.,4 Vt (e*- - L.)/ 1 3 KO
.a -I-eAr L)6 d-1 SCo rn n eci
Permit No. nfle 2004 - aet-
Master Permit No.
Permit Type (circle): Building Electrical Plumbing ecbanical Roofing
f�
Owner's Name (Fee Simple Titleholder) t eH O e/+' S 2&i i m J r. Phone #
Owner's Address . o i" S , , , r
City h\ t O 1 Sktte s State - FL Zip 3 (30
Tenant/Lessee Name Phone #
Job Address (where the work is being done) (00 S N G s- r
City Miami Shores Village County Miami -Dade Zip 531 * 3 R
Is Building Historically Designated YES NO
Contractor's Company Name &fft1 c e4- I-5 Phone # 30S'69 4 -Aoao
Architect/Engineer's Name (if applicable) Phone #
Submittal Fee SS C) .00 Permit Fee $ (D v CCF $ I , (p a CO /CC
Notary $ Training/Education Fee $ r 0 Technology Fee $ , .S a
Scanning $ Radon $ Zoning Bond $
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due ( i 1 t l -
(Continued on opposite side)
Bonding Company's Name (if applicable)
Bonding Company's Address ' ' W
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City 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 which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
The foregoing instrument was acknowledged before me this
day of rnxvrl
Q 20 (9 Ljby t'� Q 1' kr-� S _algin J
who is personally kno to o io has produces �
hL4SIco 32,u_ ° - lo-
LX
s identificatio d who did take an oath.
NOTARY PUB
Si' :
Print:
My Commission Expires:
Chc 12/15/03
Owner or Agent
APPLICATION APPROVED BY:
' _ ,,, scion #DD 0252 25 Sign:
s ' '' E Expires May I3, 2UU
f� °j Bonded Thra
Atlantic Bonding loo., III
Signature
ica Ramos -% NOTARY PUB IC:
(� L' _j , O 0 0
Contractor
The foregoing instrument was acknowledged before me this
day of h a--e by n ►) , ., el) i 5,
who is personally know me or who has produced
Expires May 13,2005
r42 � l`‘ Atlantic Bonding CO. . In4J
My Commission Expires:
Engineer
Zoning
as ' d e fication and o did take an oath.
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
i`fC�� Plans Examiner
Ramos 7
ITEM
BATH TUB
UNIT
FEE
ITEM
SWITCH OUTLETS
UNIT
FEE
ITEM
SPACE HEATERS I
UNIT
FEE
BIDET
LIGHT OUTLETS
CENTRAL HEATING I() k A?
DISHWASHER
RECEPTACLES
A/C (WIND)
DISPOSAL
SERVICE TEIPORARY
A/C (CENTRAL)
DRINKING FOUNTAIN
SERVICE SIZE IN AMPS
DUCT WORK
FLOOR DRAIN
SERVICE REPAIR/METER CHANGE
REFRIGERATION
GREASE TRAP
APPLIANCE OUTLETS
PROCESS AND PRESS PIPING
INTERCEPTOR
RANGE TOP
UNDERGROUND TANKS
LAVATORY
OVEN
ABOVE GROUND TANKS
LAUNDRY TRAY
WATER HEATER
U.F. PRESSURE VESSELS
CLOTHES WASHER
MOTORS 0- 1 HP
STEAM BOILERS
SHOWER
MOTORS OVER 1- 3 HP
HOT WATER BOILERS
SINK, POT /3 COMP.
MOTCRS OVER 3- 5 HP
MECHANICAL VENTILATION
SINK, RESIDENCE
MOTORS OVER 5- 8 HP
TRANSPORTING ASSEMBLIES
SINK, SLOP
MOTORS OVER 8- 10 HP
ELEVATORS/ESCALATORS
TEMPORARY WATER CLOSET
MOTORS OVER 10- 25 HP
FIRE SPRINKLER SYSTEMS
URINAL
MOTORS OVER 25-100 HP
COOLING TOWERS
WATER CLOSET
MOTORS OVER 100 hP
VIOLATION
INDIRECT WASTES -
A/C WINDOW
REINSPECTION
WATER SUPPLY TO:
AIR CONDITIONERS
A/C UNIT
STRIP HEATER
FIRE SPRINKLER
GENERATORS TRANSFORMERS
HEATER -NEW INST.
GENERATORS TRANSFORMERS
HEATER - REPLACE
GENERATORS TRANSFORMERS
LAWN SPRINKLER -WELL
SPECIAL PURPOSE
SWIMMING POOL
OUTLETS COM4ERCIAL
WATER SERVICE
SIGN TUBES
SEWER CONNECTIONS
SIGN TRANSFORMERS
UTILITY -SEWER
SIGN TIME CLOCK
UTILITY -WATER
FIXTURES
SEPTIC TANK
ANTENNA
RELAY
TELEVISION OUTLETS
DRAINFIELD, 4' TILE/RES.
VIOLATION
PUMA 8 ABANDON SEPTIC TANK
REINSPECTION
SOAKAGE PIT CU. FT.
CATCH BASIN
DISCHARGE WELL
_
DOMESTIC WELL
AREA DRAIN
ROOF INLET
SOLAR WATER HEATER
FIRE STANDPIPE
POOL PIPING
LAWN SPRINKLER SYSTEM
GAS RANGE
METER SET (GAS)
_
GAS PIPING
1I.. ,ADDENDUM TO BUILDING PERMIT APPLICATION
(AN APPLICATION FOR BUILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT HAS B.
OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIONS.)
PLUMBING
ELECTRICAL
MECHANICAL
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 3/9/2004
Applicant: HERBERT
Owner: SPAHN
JOB ADDRESS: 1005
Contractor SERVICE EXPERTS LLC
Local Phone: 305 - 264 -2020
Parcel # 1132060143570
Signed:
NE 95
(INSPECTOR)
Signed: (Contractor or Builder)
Mechanical Permit
Permit Number: MC2004 -34
SPAHN
HERBERT
ST
Contractor's Address: 4600 S. W. 75 AVE.
BY:
Permit Status: APPROVED Permit Expiration: 9/1/2004 Construction Value: $2,670.00
Work: CHANGEOUT 4 TON AIR HANDLER W /10KW HEATER W /DISCONNECT
Page 1 of 1
Legal Description: 5 -6 53 42 MIAMI SHORES SEC 3 PB 10 -37 LOT 17 & W1/2 LOT 18 BLK 81 LOT
Fees:
FEE2004 -2437
FEE2004 -2438
FEE2004 -2439
FEE2004 -2440
Description
Building Fee
CCF
Training and Education Fee
Technology Fee
Total Fees:
Amount
$100.00
$1.80
$0.60
$2.50
$104.90
Total Fees: $104.9
Total Receipts: --- U:$0
sy D
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 responisibility for all work
done by either myself, my agent, servants or employes.
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date CS .
Type Insp'n Final ftia,
Permit No. Nt05 qq
Phone #
Inspection Date
Approved
Correction
Re- Insp'n Fee
43
Name \Qyboy 2i
Address I OO N 4551-
Compsn E e
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 7/11/2005
Applicant: HERBERT SPAHN
Owner: SPAHN HERBERT
JOB ADDRESS: 1005 NE 95 ST
Contractor SERVICE EXPERTS LLC
Local Phone: 305 - 264 - 2020
Parcel # 1132060143570
Signed:
(INSPECTOR)
Mechanical Permit
Permit Number: MC2005 -99
Contractor's Address: 4600 S. W. 75 AVE.
Page 1 of 1
Legal Description: 5-6 53 42 MIAMI SHORES SEC 3 PB 10 -37 LOT 17 & W1/2 LOT 18 BLK 81 LOT
Fees: Description Amount
FEE2005 -9423 Building Fee $112.07
FEE2005 -9424 CCF $2.40
FEE2005 -9425 Training and Education Fee $0.80
FEE2005 -9426 Technology Fee $2.80
FEE2005 -9427 Scanning Fee $3.00
Total Fees: $121.07
Total Fees: $121.07
Total Receipts: $0.00
Permit Status: APPROVED Permit Expiration: 1/2/2006 Construction Value: $3,202.00
Work: CHANGEOUT 4 TON PACKAGE UNIT
JUL 15 PAID
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 responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
BUILDING
PERMIT APPLICATION---
FBC 2001
Qualifier Q,N M $ Cre kits IDN
(Continued on opposite side)
Training/Education Fee $
Total Fee Now Due$ I2 1 • CY3
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shows, Florida 33138
Tel:
(3 7y,5'.2204 Fax: 005) 756.8972
•,
Permit Type (circle): Building l_ Electrical � Plumbing ► echanical Roofing
Owner's Name (Fee Simple Titleholder) k r b&4- p n J —Phone # 305 ' r? s - Z 3 6 F
p 1
Owner's Address 1 0 0 5 .�J /OE _t✓ � Q&
$
City l CU % -Silo t State FL-
Tenant/Lessee Name Phone #
Job Address (where the work is being done) 1 0 05 NE 9' Mee f-
City Miami Shores Village County Miami -Dade Zip 3 3 1 .
is Building Historically Designated YES NO
1 os&g
Contractor's Company Name V t CA–. E4'rk Phone # 305-241
Contractor's Address r i Z NW 70 OAR.
City Di \ 1 GIN \i State ¶ L_ Zip 33 1 2.,
State Certificate or Registration No. CAC 05 goo Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit 13 2 0 2 Square Footage Of Work:
Type of Work: ❑Addition ❑Alteration ❑New [Repai'r'/Replace ❑ Demolition
Describe Work:
Chx.ni,e6ut q =ran par,kuy unit
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ 'N' Permit Fee $
Notary $
Scanning $ S. CO Radon $ Zoning
Permit No.
Master Permit No.
Zip 3
•--
.=1.:
•
-�.
CCF $ Z • QD CO /CC
Technology Fee $ Z .e
Bond $
Code Enforcement $ Structural Plan Review. $
u/4
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Nip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City 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 which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
Sign:
Print:
Chc 05/13/03
APPLICATION APPROVED BY:
•
Owner or Agent
The foregoing instrument was acknowledged before me this I
day of JUJ j , 2(0c, by 14e i r ► te r + ' p i1 n Te.
who is personally known to me or who has produced 1L flL
3ZO - 2` - i id and who did take an oath.
S 50-
NOTARY P
ARLEEN PEREZ
* MY COMMISSION 1 00 415482
EXPIRES: May 13, 2009
`"). OF F`01 e Bonded1MMINVMAPf Woo
My Commission Expires:
Signature
The forego
day of
who
Liv,„
NOTARY PUBLI
Sign:
Print:
Contractor
g : nstrument was acknowle before me thus .
, 20 Q L JAJ by 0.024. - r
me or who has produced
My Commission Expires:
7 /7
entification an a who did take an oath.
ICA RAMOR
* MY COMMISSION I DD 415483
f' f EXPIRES: May 13, 2009
, Bonded Thni Budget Notary Services
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
*********************** * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ** *************f r**** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
Engineer
Zoning
ITEM
BATH TLB
UNIT
FEE
ITEM
SWITCH OUTLETS
UNIT
ITEM
SPACE HEATERS
UNIT
BIDET
LIGHT OUTLETS
CENTRAL HEATING
DISHWASHER
RECEPTACLES
A/C (WIND) '^e`
DISPOSAL
SERVICE TEMPORARY
A/C (CENTRAL) 4Uly
DRINKING FOUNTAIN
SERVICE SIZE IN AMPS
DUCT WORK
FLOOR DRAIN
SERVICE REPAIRAETER CHANGE
REFRIGERATION
GREASE TRAP
APPLIANCE OUTLETS
PROCESS AND PRESS PIPING
INTERCEPTOR
RANGE TOP
UNDERGROUND TANKS
LAVATORY
OVEN
ABOVE GROUND TANKS
LAUNDRY TRAY
WATER HEATER
U.F. PRESSURE VESSELS
CLOTHES WASHER
MOTORS 0- 1 HP
STEAM BOILERS
SHOWER
MOTORS OVER 1- 3 FP
HOT WATER BOILERS
I
SINK, POT /3 COMP.
MOTORS OVER 3- 5 FP
MECHANICAL VENTILATION
SINK, RESIDENCE
MOTORS OVER 5- 8 HP
TRANSPORTING ASSEMBLIES
SINK, SLOP
MOTORS OVER 8- 10 FP
ELEVATORS/ESCALATORS
TEMPORARY WATER CLOSET
MOTORS OVER 10- 25 HP
FIRE SPRINKLER SYSTEMS
URINAL
MOTORS OVER 25-1O0 HP
COOLING TOWERS I
WATER CLOSET
MOTORS OVER 100 FP
VIOLATION (
1
INDIRECT WASTES
A/C WINDOW
REINSPECTION
I
WATER SUPPLY TO:
AIR CONDITIONERS
A/C UNIT
STRIP HEATER
I I
FIRE SPRINKLER
GENERATORS TRANSFORMERS
HEATER -NEW INST.
1 I GENERATORS TRANSFORMERS
I
i
HEATER - REPLACE
GENERATORS TRANSFORMERS
I
i
LAWN SPRINKLER -YELL
SPECIAL PURPOSE
1
I
1
I
SWIMMING POOL
OUTLETS COMMERCIAL
I I
I
WATER SERVICE
SIGN TLaES
SEWER CONNECT IONS
SIGN TRANSFORMERS (
1
UTILITY -SEWER
SIGN TIME CLOCK
UTILITY -WATER
FIXTURES
SEPTIC TANK
ANTENNA
RELAY
TELEVISION OUTLETS
DRAINFIELD, . TILE/RES.
VIOLATION
PUMP L ABANDON SEPTIC TANK
REINFECTION
SOAKAGE P11 CU. FT.
CATCH BASIN
DISCHARGE WELL
I I
I
DOMESTIC WELL
AREA DRAIN
I
I
(AN APEW,CA :ION FOR BUILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT H
OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT_ ON SUBSEQUENT APPLICA.T:
R0OF INLET
SOLAR WATER HEATE:.
FIR_ STANDPIPE
Pte'_ PIPING
LAWN SPR I NKL_r, SYSTEW
EW
GAS RAN_:
ME I E, SE (GAS
GAS PIPING
PLUMBING
ADDENDUM TO BUILDING PERMIT APPLICATION
ELECTRICAL
MECHANICAL
BUILDING ❑ ;
ELECTRICAL ❑ DATE 195
PLUMBING ❑ PERMIT N? 9821 8 21 Contractor's
License No
ROOFING ❑
Owner of
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
Lot
❑ Work to be performed under this 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 line of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict cdnformitk 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
MIAMI SHORES VILLAGE. FLORIDA
Bl.
Subdi-
vision
Sq. Ft
Value of
Project $
BY
Amt. of
Permit $
AUTHORITY
STATE OF FLORIDA,
COUNTY OF DADE. ss
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.
Date
February 4p 1960
,19
Owner's Name and Address .... ._..._Mr_n_..Ra18h_.nA.__Ratley No 5301- - -- Street N,--- W. - . .11rth - Avenue
Registered Architect and /or Engineer
Geiger Distributor Inc. 1160 Al W. 72nd Street
Name and address of licensed contractor
Location and legal description of lot to be built on:
Lot 17 B lock S ubdivision Miami Shores Seo40. 3
Street and Number where work is to be done 1005 N, x95 h ! tX ei t
State work to be done and purpose of building (by floors) SIB tAllation _. Ane- _- (1)___Trane -- Aix' -- Condition ng.
unit 3 tons Model # RUA 3
and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind of foundation Roof Covering
Estimated Total cost of improvements $ $ Amount of Permit $ 6 .00
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 building. All notices with reference to the building and its construction may
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 inspection on the site of the wort eh public notice
or notices as are required by the Act. The undersigned agrees to employ only sue ilk bcontractors, on rk to be pe foamed under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed).
3
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he 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.
Permit No Date Read, Sworn to and Subscribed before me.
Disapproved Date
(Signed)
Building Inspector My Commission Expires
Notary Public, State of Florida
PLANNING BOARD, DATE
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 appli ation 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 11r improper notice for inspection or faulty
materials and /or workmanship.