FENCEMiami Shores Village, Fla.
S T 2..a . DATE c� I ' l 0
ADDRESS 109), J. &
OWNER
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PERMIT NO. .kS S I S
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INSPECTION
TIME READY .L
INSPECTOR QL I /d
Miami Shores Village, Fla.
OWNER S L Z Cifm,Q,T DATE
ADDRESS O O E, ti
INSPECTION
TIME READY
PERMIT NO. L " 1 5S 1 q
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INSPECTOR
CONTRACTOR SI
TELEPHONE NO. 3 D S- b ^k f as
DATE
Miami Shores Village, Fla. 5
OWNER:
ADDRESS /0 9 e S
INSPECTION (tit')
TIME READY
PERMIT NO.
CONTRACTOR 5
TELEPHONE NO. b ..57) VAC
d � ° - 9 ' ' J y LJ
INSPECTOR
OWNER
ADDRESS
INSPECTION
TIME READY
PERMIT NO.
CONTRACTOR
TELEPHONE NO.
Miami Shores Village, Fla.
DATE a '' .23 - 0 0
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DATE
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Miami Shores Village, Fla.
OWNER
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INSPECTION
TIME READY
PERMIT NO.
SY 2_ 4744
TELEPHONE (*S) oC /
) 5,0
t DATE
CONTRACTOR
INSPECTOR
Miami Shores Village, Fla.
OWNER
ADDRESS
INSPECTION
TIME READY
PERMIT NO.
CONTRACTOR
S 1 - 04-,4(d DATE
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DATE /
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TELEPHONE NO. 94.
Miami Shores Village, Fla.
OWNER
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INSPECTION
TIME READY
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TELEPHONE NO.
'ERMIT NO.
= ONTRACTOR
ADDRESS D
NSPECTION
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Miami Shores Village, Fla.
OWNER S C
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DATE
DATES 25 - Zooa
Miami Shores Village, Fla.
OWNER . 2 DATE 3
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CONTRACTOR /T tS' 12 1
TELEPHONE NO. (�i)
INSPECTOR ,,Gr� y/�.�c� DATE
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Miami Shores Village, Fla.
OWNER
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TELEPHONE NO.
DATE 1,7`6a
Miami Shores Village, Fla.
OWNER
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INSPECTION
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OWNER
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OWNER
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DATE
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Miami Shores Village, Fla.
OWNER S T2 DATE 244.4_
ADDRESS D l . 11. C
INSPECTION
TIME READY �A;o
PERMIT NO. L sS ( _S
CONTRACTOR ST
TELEPHONE NO. 3 0S (1), (3'o a
INSPECTOR
ADDRESS ! 0 c l s)
INSPECTION
TIME READY a- .0r-
PERMIT NO. 45 :� s
CONTRACTOR
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DATE
Miami Shores Village, Fla.
OWNER C,Ot 2./s/D(
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TELEPHONE NO. 3 os-r q . " 3' 0 d
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OWNER
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OWNER e DATE2IS) 0 I
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PERMIT NO. j 559,-5
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INSPECTOR
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ADDRESS . A C t f _ , q y
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INSPECTION
DATE
TIME READYQ,Ll
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PERMIT NO. '
CONTRACTOR (. JI v� -(o'V Q�!�
TELEPHONE NO. 3 DS 644 P
DATE
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
1092 N.E. 94th ST
Date /� l Job Address C:, t. t,, r • BEKRidi Tax Folio
Legal Description Historically Designated: Yes No x
Owner/Lessee / Tenant ' Z COAAS Master Permit # 1 7 / 55 - 95 -
5
Owner's Address /�.2 /0
Qualifier f•O'z/
Square Ft.
Signature of o d/or Condo President Date
D1 6tary as to Owner and/or Condo President Date
My Commission Expires:
APPROVED:
Zoning Building
Mechanical J 1 < Plumbin
FEES: PERMIT /C. RADON 1 4 O 6 1
C.C.F. 1S94Ta NOTARY S
Estimated Cost (value)
Phone ads' -- C52- s 090,7
A sot g Co 5 C d �` S- �� - ee Address
SS# Phone ;r- ;e2r-as2 - 29
State # Municipal # Competency # Ins. Co.
Address
Bonding Company '¢ Address
Mortgagor Address
Permit Type (circle one): Aiiii.D ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION 4Ug 11/ ` � / g / ' - ' 4,s, �4
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
laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Signs 1, > • • ontractor or • er- Builder
/// i
L(.4 i! .` _Or / /,L
otary as to Co • acto ror Owner - Builder
My Cornmissg A$Y
Gloms) VIUAR
NOTARY PUNIC STATE OF FLORIDA
COMMISSION NO. CC714103
MY COMMISSION EXP. MAIL 1,7 .972
Electrical
Engineerin
i
OV
BOND 30
TOTAL DUE / I a t9
3 �
Date
Date
1
7�
,1
t
ly
1
- .J /3
Copy of STATE OF FLORIDA CERTIFICATION (DPER) or STATE REGISTRATION
AND DADE COUNTY COMPETENCY LICENSE.
Copy of current OCCUPATIONAL LICENSE from county or municipality where
business is located.
io -2Z -
3i z_ Co 14 97ra oh
MIAMI SHORES VILLAGE `1/F 9'I Sf cl- / /9�'�
BUILDING AND ZONING DEPARTMENT
10050 N. E. 2nd AVENUE
P!t. (305) 795-2204 FAX: (305) 75 -8972
BUILDING PERMIT /CCNTRACTORS REGISTRATION CfffiQ.IST
phe
LIABILITY (addressed to Miami Shores
R'S C MP (addressed to Miami
Construction Industry Notice of
UNG CHBDQ D OFF
z performing the work, licensed
Both signatures notarized).
d sealed by registered architect or
Classification must be on plans and
include folio number and property
to the above, must also include the
ad sealed by architect or engineer when
nd sealed by Surveyor.
t (contractor or owner).
Warranty Deed or Other Proof of Ownership if necessary.
/
Y Structural Review fee
Flood Elevation S 0 /2 p...e
Plans (Engineer).
°ducts Approvals for roof materials,
ors, aluminum carports, screen
french doors and etc.
Approvals from H S,
DADE County Impact Fee ion, Fire Department
Health Department (when applicable). DERN�
Pay to the
Order of
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 2/24/2003
Applicant: JOHN FOX
Owner: FOX JOHN
JOB ADDRESS: 1092 NE 94 NE
Bankof Am
Contractor
Local Phone:
Parcel # 1132050070180
Permit Status: Approved Permit Expiration: 8/23/2003
Work: FENCE (LOFT X 5 ' ) WOODEN FENCE
CHRISTINE JAN FOX 01 -03
1092 N.E. 94T1 STREET
MIAMI SHORES, FL 33138
cam
Building Permit
Permit Number: BP2003 -298
Contractor's Address:
Page 1 of 1
Legal Description: 5 -6 53 42 .21 AC PL OF GOVT LOT 4 PB 5 -90 BEG NE COR LOT K W133FT S '1`O
Fees: Description Amount
FEE2003 -1143 Building Permit Application Fee $60.00
FEE2003 -1144 CCF $0.60
FEE2003 -1145 Notary Fee $5.00
Total Fees: $65.60
Total Fees: $65.60
Total Receipts: $0.00
If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection
fee is $50.00, which must be paid in advance before callin s for an • s - . - 'on.
Date
Construction Value:
$(5(o
Dollars ' I -
$70.00
513 ' equipment or device described in the application herefor in strict compliance with all
th any plans, drawings, statements or specifications that may have been submitted to
63 -4i630 FL iot done in compliance with such ordinances or if the plans are changed without
1348 )r or builder named above assumes the responsibility for a thorough knowledge of the
; or in the statements or specifications and that he assumes responsibility for work done
BY:
ompliance with all ordinances and regulations pertaining thereto and in strict conformity
Village. In accepting this permit I assume responisibility for all work done by either
ACH R/r 003100277
For
1:06300004 ?1: 005488 ?5886911' 05 L3 3Y:
MAROON SHF FFIFi0- WMSF
-- The Sunshine State
LICENSE RIMER
F200- 110-65 -601 -0
CHRISTINE JAN FOX
1092 NE 94TH ST
MIAMI SHORES, FL 33138-0000
•
SEX ROT. RES* ENDORSE. •
F SW • •• • •
• • • • .
- • • 11-1 2ATE •
O1,Q� • . 11 -12-07+ • •
NRTH I»TE
0,21.65
ISSUED
01-03-01
•••• •• •. • •
• •• • • •
•••• • ••
SAFE DRRr9i•
202111200ee • • • •
Operation of • motor vshk a constitutes consent to any •Stl et9tibt required WI** •
• . • ■ • • •
• • •
• • ••••
• •
• • •••• • •
• • •
••.. • • • • •
• • •
•• ••
• • STATE OF FLORIDA)
COUNTY OF DADE) •
attached survey, performed by
performed o•:
Witness(sign and print)
Further, Affiant sayeth naught.
SWORN TO AND SUBSCRIBED before me this
Afiiant is personally /mown to me, produced
AFFIDAVIt •
• • ••• • • • •••
•
• • ••• • •
• • • • • • • • • • • •
• • • ••• • • • • •••
•
• • •'• ••• • •••
�.� • : •
•. •
•••• •
. •. • • • •• • ••
-- •.•••• • ••
The. undersigned Afnant, - v:--0 -
•
(Propr #•ner) • Fte�X attest that the
name of surveyor's company
Cp 6 : , is an accurate representation of the existing conditions and • •
date o survey)
locations of all structures on the property as of this date. .
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the .
Property without first providing a survey less than six (6) months old. The Affiant, as property owner, further
agrees to remove or obtain permits for any structures which now may exist on property whi
permitted or which may violate zoning or building code regulations. The
existence of any such structures may affect final inspections as applicable
_ day of_
otary
Afaant further understands that the
to this or other permits..
•
•
•
1 .•
ch ire not
•
as identification.
5'-a' MAX
2'-0tI
Owner's Side
=1 I
B
0
4
4
4' X4
2" X 4" Wood Pall
Concrete
_ - I = 1= I I =III=
1=111E111 - - III -I
1 - 1 1 1 - I I I - I I I 11 - 1 11 -
1" X 6" or I" X 8"
Wood pickets
• • ••• • •
•• • • • . • • • • • • ••
• • • • • • • • • • • •
•
• • • ••• • • •
• ••••
WOOD FENCES
• • • •• ••• • • •••
• • • • ••
• • • • • .
• • •
• •
•••
• • •• • •• • • • •
•• • • • ••
• • ••••• •
• • • ..
•••••••• •
wood, ••• • .
Woo
•
3I-0"
• •••••••
2915 Fences
Wood Posts
2915.1 Wood fences, so located on a property
that by zoning regulations they cannot be used
as a wall of a building, shall be constructed to
meet the following minirnum specifications.
4' -0" High or Less = 6' -0" O.C.
5' -0" High or Less = 5' -0" O.C.
(a) Fences not exceeding 5 feet in
height shall be constructed to meet
the following minimum
requirements: from nominal 4 inch
by 4 inch by 8 feet -0 inch long
posts spaced 5 fee -0 inches on
centers, having a fiber stress of
1200 p.s.i. in bendinc;, and shall be
embedded 2 feet -0 inches into a
concrete footing 1 fcot -0 inches in
diameter and 3 feet -0 inches deep.
Other components shall be
designed to comply with the
provisions of this Chapter and
Chapter 23.
(b) Fences not exceeding 5 feet and 4
feet in height respectively shall be
constructed as provided in
paragraph 2915.1 (a) herein,
except that the spacing of posts
may be increased to 5 feet -0
inches and 6 feet -0 inches on
centers for these heights.
ELECTRICAL
TYPE
Minimum Fee
QTY.
TYPI,
Dryer
()Tv.
n . i , i;
'Odtlet•Applianoe.• •.'
QTR
TYn;
Service Repair
QTY.
A/C Central 1 -3 Ton
Fan
Outlet, Wall
Service, Temporary
A/C Central 4 -7 Ton
Fire Pump
Outlet, Switch
Signs
A/C Central 8 -15 Ton
Fixture - Fluorescent
Oven
Space Heater (kw)
A/C Central 16-20 Ton
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Heater New
MECHANICAL
TYPE
Minimum Fee
QTY.
TYPE
Condensate Drain
QTY.
TYPE.
Generator
QTY.
TYPE
Refrigeration, Tons
QTY.
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wall/VVin. 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
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PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being perforrrmed quagttty(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
SECTION
BY
�AT
AB B 3
Zoning
��7
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
N Q e.
Page 4
OFFICE USE ONLY
CHECKLIST
Cl OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi- family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
PERMIT FEES
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.)
Inspector State Educational Fund
State DCA (Radon)
Code Enforcement Fine
Zoning Review
Notary
• • •••
• • • • •
• • • ••• • •
• • • • • • •
••• • • • ••• •
••• •
• • •.
• ❑
PROOF OF OWNERSHIP
( �
Att ch )
•• ••• •• ..
• • •
• • • •
• •• • • • • ••• •
❑ S 7:ARIA PI yAL
• • • • jSeptic / gewer)
❑ IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
$ (¢.005 /sq.ft.)
$ (¢.01 /sq.ft.)
• •
• • • • ••
•
•
•
(sq.ft. = x/1000
x ¢.60)
REVIEWED AND PREPARED BY:
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
TOTAL $ 6s
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
Page 2
• •
• •
• •
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Print Name
warn to and subscribed before me this j J day of
otary Public State of Florida
•••
•
• •
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• • • • •
• • • ••• •
•
•
•
•
PERMIT APPLICATION
IMPORTANT NOTICES
DO NOT BEGIN ANY WORK WITHOUT f1ANNIG RE1 ?V1•D YOUR•`9ILIDATED 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 1' MAJIyTAIN€4) 1 CCEJIN,,liiAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIV SHALL tEi{BI'TIFRtMrli iM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM ILEING DIM DLBY EVUIP111g..1JT 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
eiki
ignature of Owner Signature of Contractor / Qualifier
STATE OF FLORIDA, COUNTY OF MIAMI -DADE
Print Name
Sworn to and subscribed before me this day of
Signature of Notary Public - State of Florida
SEAL: SEAL:
Angela M Becker
My Commission D0160048
Personally known 140 R, IIht l intigt5 "" Personally known OR, Produced Identification
Type of Identification Produced: "P 1 ROQ "I `D'° ‘Di AV of Identification Produced:
PROPERTY OWNER
Name -
�'6hN a- Cvzi - t,ve_ FOX
Address
Home Telephone-- 757 n7( 0
L
Business Telephone 305._ 539_7
ill 1
Fax 3o5- 75 8 ?
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
Step 1.
Step 2.
/Job Address:
Address
Folio Number
Lot
Subdivision
Current Use of Property
Proposed Use of Property
Tenant Information
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
15/
Block
PB
PG
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
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PERMIT APPLICATION
-03 (99 F
• • • Master Permit No. • •
• Subs i �l i a l y Pern:it:N(1.
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INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
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Complete the attached permit application which must be sigfle btthe pioport3 awtnl tfkl ittalifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your app Q'ra�fig
fork will be done, a roofing application must be submit- •
ted along with this permit application. • • • • • : • • • • • . •
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
t O q \ *fizecr P't ccol i'56c6 F( 33138
Apt. City State Zip
d e scription of Work F 9.11 CQ ( \ 0 c X 5 P$
\ � : ,4 Fencs2 .
Zoning Linear Feet
Square Feet Units Floors se
alue of Work / 0 Bldg Value
a �r x Assessed/A PP raised Value
Flood Zone Base Floor Elev.
ENGINEER
Name
License No.
Address
Telephone
Fax
CONTRACTOR
Name
License No.
Address
Telephone
Fax
Qualifier Name
Type Insp'n
MIAMI SHORES VILLAGE
BUILDING DEPARTME
305- 795 -2204
Building Inspection Reques
Date Time
Permit No. P 43.
Name J'�
Address /C J9�
Company
Phone #
For Inspector:
Correction U ❑
Re- Insp'n Fee ❑
/ y 7
CJ
-- 2s? (6'0
fi� Name & Dat
l/ C
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