150 NE 95 St (7)CONTRACTOR
New Construction
Name '714. e --
(1N
`
License No. r'° E -- .. v Q
J
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r _ e� r7 t
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Address
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a .
Telephone gisj Gs1 . 7s5
ax
i (!7 Lie As
J
51
Qualifier Name 1 4 1
J T 6.r. .✓
C-.a /'
J
Foundation Only
PROPERTY OWNER
New Construction
Name _l C
CCU J
(1N
`
Address
i s 0 ni.
��
Home Telephone 2 __
J s
75•6
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Business Telephone
Relocation of Structure
I
Fax
Foundation Only
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'I Attachment
Other
Add'I Detachment
Other
0 ATIN
. .w.
� tiFN o �
INSTRUCTIONS - The following steps must be taken to ibtain a permit froth the Miami Shores Village:
Step 1.
Job Address:
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
4
MAY
Complete the attached permit application which must be s by the prope y 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.
Folio Number ° 3t •6 r3 °'Q g ( /b
Lot 8 1 Block ,2 I
DO
Subdivision J PB PG Zoning Linear Feet
Current Use of Property ` - , Square Feet
Proposed Use of Property J9alue of Work a0 d ' CD Bldg Value
Tenant Information Tax Assessed/Appraised Value
Flood Zone Base Floor Elev.
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
` / PERMIT APPLICATION
1
Master Permit No. v Q 3 ' / l
Subsidiary Permit No.
Description of Work
179 - 3 7 1
State Zip
ca. -fit- ✓ , e fir
Units Floors
ENGINEER
Name
License No.
Address
Telephone
Fax
. -7 121111111111!
Page 2
II\'IPORTANT NOTICES
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.
STA7gZ OF MIAMI -DADE
i ature of Owner
SEAL:
Print Name
Sworn to and subscribed before me this day of
Signature of Notary Public - State of Florida
Personally kn
r 1: STEPHEN E. COCKING
MY COMMISSION # DD 031747
n t! sond ) rl 4it661b 00 ati �y
STATE OF OUNTY OF MIAMI -DADE
Signature of Contractor / Qualifier
Print Name
Sworn to and subscribed before me this
Signature of Notary Public - State of Florida
SEAL:
day of
PERMIT APPLICATION
Personally known OR, Produced Identification
Type of Identification Produced: Type of Identification Produced:
Page 4
OFFICE USE ONLY
CHECKLIST
0 OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi- family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
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)
❑ OTHER
(Specify & Attach)
$3.00 per page (Scanning Fee) $
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.) $ / O 0 (sq.ft. = x/1000
x ¢.60)
(¢.005 / sq.ft.)
(¢.01 /sq.ft.)
$ '
$
$
O
REVIEWED AND PREPARED BY:
SECTION
Zoning
Electrical
Mechanical
Plumbin:
Fire
Public Works
Structural
Building Official
BY
DATE
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
PERMIT FEES
TOTAL $ 3 Rp ra O
1''S §,CING OFFICIAL
DATE:
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com
ELECTRICAL
TYPE
Minimum Fee
QTY.
TYPE
Dryer
QTY.
TYPE
Outlet, Appliance
QTY
QTY.
TYPE
Service Repair
TY.
A/C Central 1 -3 Ton
Cooling Tower
Fan
Heating Strips, each
Outlet, Wall
Vent Hood, Cost
Service, Temporary
A/C Wall/Win. Tons
A/C Central 4 -7 Ton
Dryer Vents, Number of
Fire Pump
Paint Booth
Outlet, Switch
Ventilation, Cost
Signs
Air Handler, Tons
A/C Central 8-15 Ton
Ductwork, Cost of
Fixture - Fluorescent
Piping, Flammable Liquid
Oven
Periodic Inspections
Space Heater (kw)
Barbecue •
A/C Central 16-20 Ton
Fire Sprinkler System
Fixture Light
Process/Pressure Piping
Parking Lot Lights
Supply, AC Well
Spas/Hot Tubs
Bath Fan - Vented,#
A/C Central 20+ Ton
Fireplaces, Number of
Flood Lights
Pressure Vessel
Plugmold/Strip
Temporary Toilet
Subfeeds, No. of Amps
Catch Basin
A/C Window
Gas - Propane
FPL - Load Central
Pump, Re- circulate
Posts
Temporary Water Closet
Swim Pool, Commercial
Clothes Washer
Air Conditioners
Gas Piping
Garbage Disposal
Pump, Replace - Pool
Range/Range Top
Urinal
Swim Pool, Residential
Dental Chair
Chiller
Grease Trap
Generators, etc.
Pump, Sprinkler
Pump, Sump
Relay Repair
Roof Inlet
Receptacles
Utility - Sewer
Utility - Water
Vacuum Pump
Water Closet
Switchboards
Discharge Well
Clear Violations
Ice Maker
Heat Recovery
Refrigerator, Comm. (p/PH)
Disposal
Temp Serv., Construction
Interceptor
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Heater New
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Re -pipe
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Service
MECHANICAL
TYPE
Minimum Fee
QTY
'nil.
Condensate Drain
Q . l . Y
TYPE
Generator
QTY
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
Pump, Sump
Relay Repair
Roof Inlet
Utility - Sewer
Utility - Water
Vacuum Pump
Water Closet
Discharge Well
Ice Maker
Dishwasher
Indirect Wastes
Disposal
Interceptor
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:
PAY
TO THE
O R OF
•
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 5/5/2003
Applicant: IRENE
Owner: RINEY
JOB ADDRESS: 150 NE 95
Contractor MR C'S SEPTIC TANK
Local Phone: 305 - 651 -7859
Parcel # 1132060132840
Fees:
FEE2003 -2639
FEE2003 -2640
FEE2003 -2641
FEE2003 -2642
Description
Building Fee
CCF
Builders Bond
Notary Fee
Total Fees:
MR. C'S SEPTIC & DRAIN, INC.
OPERATING ACCOUNT
P.O. BOX 693239 305- 651 -7859
MIAMI, FL 33169 -0239
(//A
Plumbing Permit
Permit Number: PL2003 -119
RINEY
IRENE
ST
Contractor's Address: P 0 BOX 693239
Legal Description: 1 53 41 6 53 42 MIAMI SHORES SEC 1 AMD PB 10 - 70 LOTS 8 & 9
r ! ki .& •
�I�I) Washington Mutual
Washington Mutual Bank, FA
Miami/199th Street Financial Center 1719 �� t000 •
Miami, Ft. 169 J 24 hoot Customer Service
175 NW. 19 th
040000 66 4 70 I: 26 ?084 13 II: 38 30 3084 20
DATE
Amount
$80.00
$1.20
$300.00
$5.00
$386.20
Permit Status: APPROVED Permit MT" ""
-,
1,,104- �.
. _ . , •, ;;11:44,, »,�..,, _ - g 6 4 7
• 63- 8413 -2
$
RS ' =OA -'
Page 1 of 1
Total Fees: $386.20
Total Receipts: $0.00
; pertaining thereto and in strict
assume responisibility for all work
BLK 21 LOT
AGENT:/#. � - I
?ROPERTY 1D•#://,. 7 f ,° . _
•
'2� � - n/- P, 9 , [ /Township /Range /Parcel No. or Tax ID Number]
CO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
'ROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
- - - - - -- ---------- - - - - -- _ _ _________ ____ __
'ROPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [ ) NO NET USABLE AREA AVAILABLE: A C�
'OTAL ESTIMATED SEWAGE FLOW: �7 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHE - TABLE - E -7 f
AUTHORIZED SEWAGE FLOW: °1ilr, GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
TNOBSTRUCTED AREA AVAILABLE: (Z -y SQFT UNOBSTRUCTED AREA REQUIRED: 4 - SQFT
D S
-
42 ' Q
!Y 64r/! A
(INCHES(FT1)[ABOVE /, `LOW BENCHMARK /REFERENCE POINT
APPLICANT:
LOT : `l
ENCHMARK /REFERENCE POINT LOCATION:
LEVATION OF PROPOSED SYSTEM SITE IS �`
HE MINIMUM SETBACK WHICH
URFACE WATER: tt95) FT
ELLS: PUBLIC: ,414 FT
UILDING FOUNDATIONS:
ITE SUBJECT TO FREQUENT FLOODING: [ ] YES ( ] NO 10 YEAR FLOODING? [ ) YES [NY/NO
YEAR FLOOD ELEVATION FOR SIT E: FT MSL /NGVD SITE ELEVATION://0 . FT MSL /NGVD
)IL PROFILE INFORMATION SITE i/ r -0
funsell Color
BLOCK:
Texture
SDA SOIL SERIES: /,44(0
'E EVALUATED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
02/
1 4 0 .
/Vet/ .
SUBDIVISION:
CAN BE MAINTAINED FROM TH E
DITCHES /SWALES:
LIMITED USE: /JAI. FT
� , CrO FT PROPERTY LINES.
Depth
to
to
VO77
to
to
to
to
to
to
L4 xi'
SERVED WATER TABLE: 0 / 4 i ie- INCHES [ABOVE /
FIMATED WET SEASON WATER TABLE ELEVATION:
3H WATER TABLE VEGETATION: [ ] YES [ NO
CL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
UINFIELD CONFIGURATION: [ ] TRENCH [ t,.T BED
(ARKS /ADDITIONAL CRITERIA:
015, 10/96 (Replaces HRS -H Form 4015 (Pape 3) which may be used)
:k Number: 5744 -003 - 4015 -1)
BELOW)
PROPOSED S,717 TO THE FOLLOWING FEATURE
49n FT MALLY WET? [ ] YES [� NO
PRIVATE : FT NON - POTABLE: L� -
W FT `POTABLE WATER LINES: FT
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color
1 .! 'ft L� V
Texture Depth
to
.
to
to
- to
( to
to
to
USDA SOIL SERIES: t.AL/ j j 1-ir J'
EXISTING GRADE. TYPE: [PERCHED / APPARENT]
INCHES [ ABOVE BELOW ) EXISTING. GRADE.
MOTTLING: [ ] ['] NO DEPTH: - -_ INCHES
DEPTH OF EXCAVATION:od1 Lg?
[ ) OTHER (SPECIFY)
DATE: y
age 3 of 3
tie: Each block represents 5 feet and 1 inch = 50 feet.
.t._ ,
1 71 - . i
--[
rt
7 I : •
• : 1 - •
'• -
7- – I • 1
r bik
•
• 1
Plan submitted b
Approved
STATE OF FLORIDA C - /.7) N
::: -
DEPARTMENT OF HEALTH
APPLICATION FOR ON SEWAGE. DISPOSAL SYSTEM CONSTRUCTION PEZT .-. ;:-.4) 6
, -, . 40(34
Permit Application NiMber
-1-
ALL CHAN
10/90 (Replaces )4RS-H Form 4015 which may be used)
Jetier: 6744-002-4015-6)
_ .
PART II - SITE PLAN-
, • ' 1 ' ' ' • ' 1 ; I 1 .
1 '
i i : ; • ; I I , . 1
- -
-- — . . • ./ 4 , I. t i
= --., - - 7 - ....1. -- ' -- ._.- t .1
• ,
1 ._
AY
4 --- — ,
. 1 I -- fl. .4_,.:.:.■
4 c
■
•
ES MUST BE APPROVED BY THE COUNTY HEALTH. DEPARTMENT
Signature
Not Approved Date
County Health Department
Page 2 of 3
CONSTRUCTION PERMIT FOR:
New System [N] Existing System
Repair [0] Abandonment
APPLICANT: "` tJ/ s '✓ • 0 ,
, 11 , y
[ ul
(xl
PROPERTY ADDRESS*
LOT:
STATE OF FLORIDA
DEPARTMENT OP HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION. PERMIT
/.S .0 N , E. 9
BLOCK: ' SUBDIVISION:
PROPERTY ID #: _ ' ( - 3206- v 13 _ Z S 7 0
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION.
SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T C.q /S / GALLONS / GPD SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
A [ q 6 U ] GALLONS / GPD ~ CAPACITY MULTI- CHAMBERED /IN- SERIES. [ ]
N [ — ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ._ ] GALLONS DOSING TANK CAPACITY [ ] GALLONS @ [ ] DOSES PER 24 MRS # PUMPS [ ]
D "(3 00 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [V] STANARD [ 1 FILLED [
I CONFIGURATION: [ ] TRENCH [] BED [ ]
/ a► 2 0 r, r L - 7 e,c/• (Jv .6.v.0
N
F
I
E
L
D FILL REQUIRED: [00 ] INCHES
0
T
H
E
R
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE [Z 5,201 INCHES /FT] [ABOVE /BELOW BENCHMARK /REFERENCE POINT_
BOTTOM OF DRAINFIELD TO BE [S),21-.1 [INCHES /FT] [ABOVE BELOW] BENCHMARK /REFERENCE POINT
SPECIFICATIONS BY: " / V,
APPROVED BY:
DATE ISSUED:
1-1- 23 10 3
DH 4016, 12/99 (Page 1) (Previous Editions
f • �ccet4L Sly os /�/ 33/
•
/ A.(i -: s S Qc . 1
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
ITLE:
May Be Used)
[J] Holding Tank [N] Innovative
[fJ] Temporary [ l
] MOUND [ ]
EXCAVATION REQUIRED: [3 $ ] INCHES
INSTALL 1 " OF SLIGFTIHLY LIM1 TED SOIL
UNDEK i1011\7171 5F altbrINF
Tr-US r r'T? yrit�', '~ is-TOT Yrq i(S)
cHD
EXPIRATION DATE: - 7 23103 -
Page 1 of 3
Part 1 - Health Department
Part 2 - Applicant
Part 3 - Installer /Contractor
Part 4 - Building Department
PERMIT NO. - 1226
DATE PAID:
FEE PAID: 7 S , 00
RECEIPT Si: g / D 7 s
l -S(',- 1c3 /n
3'
BUILDING ❑
ELECTRICAL ❑
PLUMBING ❑
i0OFING ❑
Owner of
tuilding 6
address of
tuilding
MIAMI SHORES VILLAGE. FLORIDA P
DATE �" 19*
Contractors
License No
PERMIT N? 6669
j
%rchitect
ontractor
Jr Builder L% + -i4> d r
.egal Lot
Description
In consideration A of the issuance to me of this
ertaining themio and /in strict conformity y th the
ptingJhis ermi I ssumetespbnibility for all
_
CONTRACTOR O UILDER
BI
Work to be performed under this Permit
Signed
Subdi-
vision
Value of
Project $
•
This permit is granted to the contractor or build dr named above to c struct the building or to install the equipment or device described in the application
terefor in strict compliance with all ordinances pertaining thereto and th the understanding that the work will be performed in compliance with any plans
:rawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked at any
me 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
ranted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and regulations
, ertaining 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
one by his agents, servants or employees.
INSPECTOR
ermit{ I ree to perform the work vctZed hereunder in compliance with
ans, drawn gs, state entta or s ecificahons pubmitted to the proper authorities
ork done y either /. myse , t ages t, ser/tant or employe. �f
BY
d
Amount of r
Permit $
AUTHORITY