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PLUMBING-- - C:.39ETS E9 ATH TUBS SHOWERS I.AVA• remiss SINKS SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT' NS TOTAL FIXTURES CONTR. LIST CielaCK SMPIIC TANK SEWER CONN. DRAIN PI ELD SCIAKAGE PIT GREASE TRAP SOLAR HEATER DEEP - WELL SPRKLR. SYSTEM SW IM'G POOL CONTR. LIST CHECK v/ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT - P'ennit No.__. Wit-_ .._ r Date aI �- �l /q (� Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building 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 Stab; 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 work. n y / Owc.ar's Name and Address Pig ° 5:1 A ni - _ No.-__1O-tl---_Scs_ Street_ -- 9' Z Registered Architect and /or Eng // k�eer____-- __— ��______ _____— ___�._______ - Employing Plumber's Name._!!r__,�Li�IC't1��'!/_1 h€ �__ -. No.__ 4 0 __.__ _______ Street_kli.%-__! S f 57 Location and Legal Description Lot___ .. ________ _ Block_ - - - -- Subdivision ._ ____.---- Street and Number where work is to be performed -No L ®d e S t- f_J.l F _9e 5r____ ........ Steto work to be performed and purpose of building (By Floors) _-_-_ Se Lf_? -4 f4'- -- S'- -" - New Building _____ ...... ._. -__ Remodeling --_ -_ ______ Addition Repairs Size Septic Tank ______Type of Tank Capacity Gals Feet of Drain Tile________ __._moist. Feet of Tank or Drain Field from Well Nature of Water Supply: City-Well. if __Size of Soakage Pit Amount of Permit $ (Signed) _ The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligati s as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Pennane , - upplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors emp ed 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 work such • ublic notice or notices as are required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as licensed by Miami Shores Village. (Signed)... No. of Stories. _ umbing Inspector. 06 Master El ber. are STATE OF FLORIDA, COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared 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. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of $1.110 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship. Permit No Size Septic Tank Feet of Drain Tile STATE OF FLORIDA, } Application is hereby ii ade for the approval of the detailed statement of the plans and specifications herewith submitted for the building 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 Stile of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be comp;ied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address Registered Architect and /or En eer___.___.__ Employing Plumber's Name Location and Legal DescriptiT: Lot ___.____ ........ ________.____. Block Street and Number where work is to be performed —No ,State work to be performed and purpose of building (By Floors)__ few Buildin Remodeling__-.__ Addition Repairs No. of Stories. Type of Tank __Dist. Feet of Tank or Drain Field from Well Nature of Water Supply City, Well.___._____ ______Size of Soakage Pit - - - - - -- — - - - - - -- — - — - 1 .l -- - - ' -- -- Amount of Permit $------------ ------ --• __---- ---- -- - - -- — — (S�ed) — - — — - - =y fi Plumbing Inspector. - The undersigned applicant for this building permit does hereby certify that he understands and accepts his obli Lions as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Pennan fit Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub- contractors emp eyed by him in the work to be performed under this permit; and will Fost or cause to be posted for inspection on the site of the work such i ublic notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are Licensed by Miami Shores Village. se. COUNTY OF DADE. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT' APPLICATION FOR PLUMBING `' ;► <x.Nl�° Fi ��_ w___•- _- ___ —_- ....... No._ Street Capacity Gals -------------------- ( Signed - - - - -- Date ) ;< 3 Street -_—__.____ Subdivision.. Street Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by nle 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. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by improper notice for inspection, or faulty metaaials and /or worlmvanship. s td My Commission Ecpires Notary Public, State of Florida CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBE URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT•NS / ��,`J�, FU ,-'- TOTAL FIXTURES CONTR. LIST °d a °, d •< g •0 CHECK — SEPTIC TANK SEWER CONN. DRAIN FIELD LOAKAOE PIT GREASE TRAP Set HEATER DEEP WELL SPRKLR. SYSTEM SWIM'O POOL S 7(9.,, CONTR. LIST '/ d / -- CHECK Permit No Size Septic Tank Feet of Drain Tile STATE OF FLORIDA, } Application is hereby ii ade for the approval of the detailed statement of the plans and specifications herewith submitted for the building 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 Stile of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be comp;ied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address Registered Architect and /or En eer___.___.__ Employing Plumber's Name Location and Legal DescriptiT: Lot ___.____ ........ ________.____. Block Street and Number where work is to be performed —No ,State work to be performed and purpose of building (By Floors)__ few Buildin Remodeling__-.__ Addition Repairs No. of Stories. Type of Tank __Dist. Feet of Tank or Drain Field from Well Nature of Water Supply City, Well.___._____ ______Size of Soakage Pit - - - - - -- — - - - - - -- — - — - 1 .l -- - - ' -- -- Amount of Permit $------------ ------ --• __---- ---- -- - - -- — — (S�ed) — - — — - - =y fi Plumbing Inspector. - The undersigned applicant for this building permit does hereby certify that he understands and accepts his obli Lions as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Pennan fit Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub- contractors emp eyed by him in the work to be performed under this permit; and will Fost or cause to be posted for inspection on the site of the work such i ublic notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are Licensed by Miami Shores Village. se. COUNTY OF DADE. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT' APPLICATION FOR PLUMBING `' ;► <x.Nl�° Fi ��_ w___•- _- ___ —_- ....... No._ Street Capacity Gals -------------------- ( Signed - - - - -- Date ) ;< 3 Street -_—__.____ Subdivision.. Street Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by nle 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. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by improper notice for inspection, or faulty metaaials and /or worlmvanship. s td My Commission Ecpires Notary Public, State of Florida c-i _ Date �� , 19 Owner's Name and Address /A 5 Z 6 E' No j',3 CI r> Street. 21 ° ''2 4 : -44, 4 4i Registered Architect and /or Engineer 2 Name and address of licensed contractor Location and legal description of lot to be built on: Lot STATE OF FLORIDA, I COUNTY OF DADE. ss. 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 previsions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Divisirn 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. Block Subdivision / g t MIAMI SHORES VILLAGE Disapproved r .rr� Dae (Signed) 6 i d ng Inspector BUILDING INSPECTION DEPARTMENT Acv ;) Roof Covering o t � J c x /r Street and Number where work is to be done State work to be done and purpose of / building (by fl rs) Ie ° Sieier e ?i,/, G^ pL �" d G`1 Nu Y r cri"+a �C�(� S�b.' ' and for no other purpose. New Building Remodeling Addition Repairs No. of Stories To be constructed of C:B t) Kind of foundation a_ „ f r Estimated Total cost of improveme nts :2,/% � .1 ' Amount of Permit $ Zone cubage required._. _,1L, OV _Plan Cubage Distance to next nearest building , F= ` Size of Building Lot Maximum live load to be borne by each floor I hereby submit all the plansund specification � f+pr said building. All notices with reference to the building and its construction may be sent to \il'?F'r _`�._ y 1._.. i.x "4,.. — 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 hint in the work to be performed uncle] this permit; and will post or cause to be posted for inspection on the site of th work such public notice or notices as are required by the Art. The undersigned agrees to employ only such subcontractors, on woylq to l e,¢erformed under this permit, as are licensed by Miami Shores Village. < \` ./ Remarks (Signed) i(. U: 1 %� t/ v , 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 oti s � � Read, Sworn to and Subscribed before me. Notary Public, State of Florida My Commission Expires 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 application 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 by improper notice for inspection or faulty materials and /or workmanship. ' X . 9 ; t - A , C - 9 / 3 0 if I I c;)' yf ;7 • .7 • c ,)( 22 / e 0 0 / ,`,"/ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building 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 work. Owner's Name and Address Registered Architect and /or Engineer___ Employing Plumber's Name_ Location and Legal Description Lot_____ ..... Street and Number where work is to be performed—No /,0 State work to be performed and purpose of building (By Floors) __ ____ _ New Building __. Remodeling_____ _____ Addition_ Amount of Permit $ APPLICATION FOR PLUMBING " `;�.a NIT N (Signed)_ Date 2- — 4— I , Streei - h Street. ,/ fl Subdivision Repairs No. of Stories. Size Septic Tank 7 a a Type of Tank__ Capacity Gals Feet of Drain Tile. 774 Nature of Water Supply: City -Well ........... _______Size of Soakage Pit __Dist. Feet of Tank or Drain Field from Well (Signed)- v t 1 /(e lumbing Inspector. 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 com- plied 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 work such public notice or notices as are requited by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, ¢ 7are Ltcrnsed by Miami Shores Village. Master Plumber. STATE OF FLORIDA, I es. COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by ine 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. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by improper notice for inspection, or faulty materials and/or workmanship. CLOSETS BATH TUBS S LAVA TORIES SINKS SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT' NS TOTAL FI %TURES CONTR. LIST • CHECK SEPTIC TANK SEWER CONN. DRAIN SOAKAGE FIELD PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SW IM'G POOL CONTR. LIST - -- CHECK MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building 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 work. Owner's Name and Address Registered Architect and /or Engineer___ Employing Plumber's Name_ Location and Legal Description Lot_____ ..... Street and Number where work is to be performed—No /,0 State work to be performed and purpose of building (By Floors) __ ____ _ New Building __. Remodeling_____ _____ Addition_ Amount of Permit $ APPLICATION FOR PLUMBING " `;�.a NIT N (Signed)_ Date 2- — 4— I , Streei - h Street. ,/ fl Subdivision Repairs No. of Stories. Size Septic Tank 7 a a Type of Tank__ Capacity Gals Feet of Drain Tile. 774 Nature of Water Supply: City -Well ........... _______Size of Soakage Pit __Dist. Feet of Tank or Drain Field from Well (Signed)- v t 1 /(e lumbing Inspector. 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 com- plied 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 work such public notice or notices as are requited by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, ¢ 7are Ltcrnsed by Miami Shores Village. Master Plumber. STATE OF FLORIDA, I es. COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by ine 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. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by improper notice for inspection, or faulty materials and/or workmanship. PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date / Job Address 1586 N E . 96th Street /fax Folio Legal Description Historically Designated: Yes No Owner/Lessee / Tenant WARREN V. MEACHAM Master Permit # ( 10 ?8 V Owner's Address 1086 N.E. 95th Street Miami Shores Phone -5308 Contracting Co. COASTAL PI 1 1MR T NG co - OF MIAMI Address 285 N.E. 185t , treet Mi cmi . F1 33179 Qualifier ROBERT E. BRINCEFIELD ss# Phone 651 State # CFCO 19042 Municipal # Competency # 6264 Ins. Co. CNA Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION REPLACE EXISTING ELECTRIC WATER HEATER Square Ft. Estimated Cost (value) $200 00 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 thai: 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. Signature of owner and/or Condo Pres: dent FEES: PERMIT Date 7 Notary as to Owner and/ Co4 " :F9 • My Commission Expires: ; � 28 9 4 py � i "g, , FCC' 477159 • 6A. Fa fn- InstA• • 4114 .. ..... ���� Signature of Contractor or Owner -B der %%0% /il , to i 1i Notary as to Contractor or 0 My Commission Expires: F.* ; 4 •••• :,t o � FCC 477159 : a v 9 � {.• .'by ° °credo% �.•' p•. Pain-Instono B ' I CfS Pat // \ ��� (.. Date Dae RADON C.C.F. NOTARY TOTAL DUE APPROVED: Zoning 13uilding Electrical Mechanical Plumbing r / ^\ l Engineering Owner of Building Architect Contractor or Builder Legal Description Address of Building Lot CONTRACTOR OR BUILDER MIAMI SHORES VILLAGE. FLORIDA BUILDING ❑ ELECTRICAL ❑ PERMIT N? PLUMBING kl N. 9 5 9 9 ROOFING ❑ Bl. Work to be performed under this Permit — Subdi- vision Signed • 1 DATE 1 Contractor's License No Sq. Ft Value of Project $ Amt. of Permit $ ' �7 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 ouch 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 ohown 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. r' BY 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. BY AUTHORITY MIAMI SHORES VILLAGE. FLORIDA BUILDING ❑ ELECTRICAL ❑ PERMIT N9 PLUMBING `► N. 9594 ROOFING ❑ Owner of Building_ Architect Contracto or Builde Legal Descripti Address Building 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 ouch 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 Chown 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. , f/ r ` / e ' Signed • t J t ' BY 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 i :he 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 r • DATE Work to be performed under this Permit_— / 195 ' Contractor's License No BY - AUTHORITY / r C t .I. :y (44 t. % ,- ( 1 Subdi- vision n Lot Bl ,f 1 jl f r f pc t r sq. Ft Amt. of Permit . t $ / , w ' ' -' Value of Project $ MIAMI SHORES VILLAGE. FLORIDA BUILDING ❑ ELECTRICAL ❑ PERMIT N9 PLUMBING `► N. 9594 ROOFING ❑ Owner of Building_ Architect Contracto or Builde Legal Descripti Address Building 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 ouch 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 Chown 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. , f/ r ` / e ' Signed • t J t ' BY 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 i :he 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 r • DATE Work to be performed under this Permit_— / 195 ' Contractor's License No BY - AUTHORITY