815 NE 99 St (14)Issue Date: 6/23/2006
Owner's Name: EZRA AND EMILY HAYNES
Permit Type: Paint
Work Classification: New
Job Address: 815 99 Street NE
Comments:
EXTERIOR PAINT
Additional Information
Miami Shores Village, FL 33138-
Building Department File Copy
Applicant Signature
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204 Fax: (305)756 -8972
Permit
Expires: 12/17/2006
Contractor(s) Phone Primary Contractor
HOME OWNER
Yes
Type_of_Work
Additional Info
Color
Classification
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, servants, or
employes. I understand that separate permits are required for ELECTRICAL,
PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING
POOL work.
OWNERS 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. Futhermore, I authorize the above -named contractor to do
the work stated.
Parcel #:
Block:
Section:
Permit Status: APPROVED
Permit Number: PT -6 -06 -1666
Phone:
1132060340100
Lot:
PB:
Total Square Feet: 0
Total Valuation: $ 500.00
Required Inspections
Final
Fees Due Amount
CCF $0.60
Education Surcharge $0.20
Permit Fee $60.00
Technology Fee $1.50
Total: $62.30
Invoice Number
PT - 6 - 06 - 25293
Total:
Amt Due
$62.30
IJUL 1 8 PAID
Amt Paid
NOTICE: In addition to the requirements of this permit, there may be additional
restrictions applicable to this property that may be found in the public records of
this county.
AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER
GOVERNMENTAL ENTITIES SUCH AS WATER MANAGEMENT
DISTRICTS, STATE AGENCIES, OR FEDERAL AGENCIES .
i cir7
JAN ° 261
Passed
Inspector Comments
Failed
Correction
Needed
Re- Inspection
Fee
($75)
No Additional Inspections can be scheduled
re- inspection fee is paid.
until
Inspection Number: INSP -20445
Permit Number: PT -6 -06 -1666
Inspection Date: 01/08/2007
Inspector: Grande, Claudio
Owner:
,
Job Address: 815 99 Street NE
Project: <NONE>
Miami Shores Village, FL 33138-
Contractor: HOME OWNER
Building Department Comments
Friday, January 5, 2007
..•
::�vuIL'Y
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Block:
Permit Type: Paint
Inspection Type: Final
Work Classification: New
Phone Number
Parcel Number 1132060340100
Lot:
Page 1 of 2
Date
Tuesday, July 18, 2006
07/18/2006 Check
Receipt
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000
Phone: (305)795 -2204 Fax: (305)756 -8972
1
Permit Number: PT -6 -06 -1666
Invoice Number: PT -6 -06 -25293
Applicant: EZRA AND EMILY HAYNES
Company Name:
Owner Address:
815 NE 99 ST
MIAMI SHORES, FL 33138
Job Address:
815 99 Street NE
Miami Shores Village, FL 33138-
Payment Type Check Number
1389
Amount
$62.30
Change
$0.00
Total Payment: $62.30
Page 1 of 1
Miami Shores Village
1 oEP Building Department
�,, r� 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
S P Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle): : uildin: Electrical Plumbing Mechanical Roofing
Carol S. Stobs
Owner's Name (Fee Sim. older) Phone # 305 - 751 -1692
Owner's Address
City Miami Shores Florida 33138
Tenant/Lessee Name
815 N.B. 99th Street
State
Job Address (where the work is being done) 815 N.E. 99th Street, Miami Shores, FL 33138
City Miami Shores Village County Miami -Dade Zip 33138
FOLIO / PARCEL # )) 32c603 V ( 0 1 0 0
Is Building Historically Designated YES NO X
Coal
Contractor's Company Name
Contractor's Address
City
Qualifier Name
O.oO
Value of Work For this Permit $
Zip
Master Permit No.
Phone #
Phone #
State Zip
Phone #
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
Square / Linear Footage Of Work:
RECEIVED
JUN �; 0 2006
BY: !�OP��CcqDlt'Z-
Permit No. 06 - 1666
Type of Work: ['Addition ['Alteration ew /�-, ❑ Repair/Replace ® Demolition
Describe Work: ------ !,f.�sft e=
Vi eA1^.4 vtdsiQ -0E- ' ousE' •
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ COO �� CCF $ C CO /CC
Notary $ Training/Education Fee $ 0. Technology Fee $) - �
Scanning $ Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverse side -*
Bonding Company's Name (if applicable)
Bonding Company's Address
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
(Revised 02/08/06)
NOTARY PUBLIC:
APPLICATION APPROVED BY:
Sign: + -%'/ _. .
�p:' c UNDA S. S Yth
Print: ,7,,, ( :s- MY COMMISSION # DD 185088
` EXPMts: June 19, 2007
ir Bortled Th u �atary Pubkc Uri nmiters
My Commission Ex
As identification and who did take an oath.
Owner or Agent ee�� Contractor
The fore r : ing instrument was acknowledged / before me thisc a The foregoing instrument was acknowledged before me this
day of i jl,r 20��� le
, by (.A'B'C f ph5 , day of , 20 , by
who is � rsonally known to me or who has produced who is personally known to me or who has produced
as identification and who did take an oath.
Signature
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
4-4e_ .ft.6iu,„,
Plans Examiner
Engineer
Zoning
Date
City
Owner's Name
Owner's Address
olM
5 14 oho s State 1 L
Miami Shores Village
Paint Color Approval and Agreement
3 - 05- psi -I"1- t�
C u - 6 • U�"1-s Phone# 3 Os H
el s- aq+' s e -
Job Address (where the work is being done) � e •
City Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name (if applicable) Phone #
MI elements on the site must be listed and indicate the color to be painted
Ca.
Walls JJQ
Fascia •, V L ( P
Drip Cap /drip Edge
Soffit f ,
Roof W (ANA ' l T e •
r
Flower bias W L , r e
Shutters (,47
Awnings
Chimney
Doors and door jams f • , W t
Garage doors : II �,^,VV A �e
Railings W\4 r - e
Fences
Decorative metal
Signature
All brick (simulated or regular)
APPLICATION APPROVED BY:
5
4/
Owner or Agent
Zip
33)38
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.
Date 61 {Z)O
Date
CPI IC)7
chc 6/18/03
MIAMI SHORES VILLAGE
$UILDING DEPARTMENT
305- 795 -2204
Bui1.ng Inspection Reques
Date V -
Type Insp'n Pari
Permit No. 6P
O Name C /�'"`�r
Address is Af qQV
Company
Phone #
Inspection Date
Correction
Re- Insp'n Fee ❑
I:
MIAMI SHORES VILLAGE
I UILDING DEPARTMENT
305- 795 -2204
Buildin I nspection Request
Date /�/
Type Insp'n
Permit No. r v - + - s
✓.
Name
Address
Company
Phone #
Inspection Date
Correction
Re- Insp'n Fee ❑
C 7\ sr-
BUILDING
PERMIT APPLICATION
FBC 2001
Contractor's Company Name C C2A/ti V
Type of Work: ❑ �*t ❑Alteration
Describe Work: c /4
4 7 - p 0k (Continued on opposite side)
Total Fee Now Due $
ilia
Miami Shores V i l l a g e RECEMED NT?
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
❑New
Permit No. 8
Master Permit No.
.Z /R C i1/4 /V F S Phone #
-
e1
- ns
Permit Type (circle): Building Electrical Plumbing Mechanical Rooting
Owner's Name (Fee Simple Titleho . er
Owner's Addres
-----,[
City' (37797/ ),' /t e-s State `=L -. Zip . 55 f
Tenant/Lessee Name Phone # 7( Y71- 9' /7
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Phone #
Contractor's Address
City State Zip
Qualifier
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
rr����,, ci CJ
$ Value of Work For this Permi �`' Square Footage Of Work:
❑ Repair/Replace El Demolition
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ `v - W CCF $ 1 (cC) • CO /CC
Notary $ 5 -0 v Training/Education Fee $ c 2 1) Technology Fee $ 1..SO •
Scanning $ Radon $ Zoning 1 Bond $
Code Enforcement $ Structural Plan Review. $
Bonding Company's Name (if applicable)
Bonding Company's Address
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.
Signaiur
NOTARY
Sign:
Print:
Chc 05/13/03
The foregoing instrument f was acknowledged before me this J The foregoing instrument was acknowledged before me this
day of 2004, , by a N aD.5 , day of , 20 _, by
who is ersonally known to me or who has produced Dui_ .who is personally ' , to me or who has produced
My Commission Expire
* * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
* * * * * * * * * * **
As identification and who did take an oath.
Mabel `' argue� TARP PUBLIC:
• _ : Commission #DD231 4
Jul 13 2007 Sign:
o?, Bonded Thru
Atlantic Bondin• Co, Inc Print:
&(/ //cr,
as iden
My Commission Expires:
Contractor
ation and who did take an oath.
******************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
r /l * * * * ** *`* 2004 * * * * * * * * * * * * * * * * * * * * * * * * * * * **
************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
Engineer
Zoning
Miami Shores Village
• •Paint Color Approval and Agreement
Date e r� G
/1'/-i G - / 5 Phone # '' / ! Y
Owner's Name
Owner's Address ,4 / �✓�
City//Ir�%
h //if e State Zip 5/5
Job Address (where the work is being done) r/5 — /L 9 / 1
City Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name (if applicable) Phone #
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
All elements on the site must be listed and indicate the color to be painted
Walls
Fascia
Drip Cap /drip Edge
Soffit J/
Roof
Flower bins
Shutters \
Awnings
Chimney
Doors and door jams Y
Garage doors re
Railings
Fences
Decorative metal
All brick (simulated or regular)
Stucco bandin
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.
Signature
c
APPLICATION APPROVED BY:
? ?J 3 S'
;
Date
Date .
chc 6/18/03
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305- 795 -2204 Permit Number: BP2004 -835
Printed: 6/17/2004
Applicant:
Owner:
JOB ADDRESS: 815 NE 99 ST
Permit Status: APPROVED Permit Expiration: 12/12/2004 Construction Value: $300.00
Work: PAINT
Contractor
Local Phone:
Parcel # 1132060340100
Signed: (INSPECTOR)
Building Permit
Contractor's Address:
Page 1 of 1
cb
,i
Legal Description: MIAMI SHORES SEC 8 PB 14 -33 LOT 14 & E1/2 LOT 13 BLK 169 LOT SIZE
Fees: Description Amount
FEE2004 -6257 Building Painting Fee $60.00
FEE2004 -6258 CCF $0.60
FEE2004 -6259 Notary Fee $5.00
FEE2004 -6260 Training and Education Fee $0.20
FEE2004 -6261 Technology Fee $1.50
Total Fees: $67.30
Total Fees: $67.30
Total Receipts: $67.30
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:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 4 t Job Address/ 2 f .t f Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant A ( 4./A/eK 4411 G /5)/V e f Master Permit # 9 933 - 5
Owner's Address $ / 5 A /fl (9 ft Phone 76 9 / t' 9
Contracting Co' 64,h&i2hJ Address
Qualifier SS# Phone
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one) T : UILDING ECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION Xi ;c7/
Square Ft. Estimated Cost (value 3,
U °
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.
—�� � y�ate
)3 17� b
Signature of owner and/or Condo President Date . j� f Contractor or Owner- Builder
FFICIAI, NOTA RY CFA i
Notary as to Owner and/or Condo President Date N:: as to Contrac or or Own�rl$>Al$rVII.LAR Date
My Commission Ex sir PUBLiC S; ATE OF FLORIDA
COMMISSION NO. CC714103
MY COMMISSION EXP. MAR 1,2002
FEES: PERMIT �v RADON C.C.F. ` 60 NOTARY BOND
My Commission Expires:
APPROVED:
Zoning
Mechanical
Plumbing
Electrical
Structural Engineer
DATE: 2G "
OWNER'S NAME: �'. r y®f Q f PHONE: ,�G� = 75 —�� P
ADDRESS: e/,4"" jf /r 9 9 5/ , � /GtG�I� (slioil S �� gygr
************************************ * * * * * * * * * * * * * * * * * * * ***** *** * :.,
ADDRESS OF SITE: Sim/
CONTRACTOR & LICENSE (if applicable)
COMPANY NAME: PHONE:
MIAMI SHORES- VILLAGE
Paint Color Approval and Agreement
******** ***************** * xXxx * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
All Elements on the site must be listed and indicate the color to be painted.
Walls MJ l `) 6 rl 0 9 Q= s 42 11/, a:12 erz.r 7 /ma
Fascia n
Drip Cap/Drip Edge o
0
Soffit (,vet 7G pi
Roof En
Flower Bins r
Shutters im
Awnings H
Chimney x
Doors and door jams i2." L z
Garage Doors .Gv4e/r/ o
Railings b7 z
Fences
Building
Decorative Metal
All brick (simulated or regular) e/.4 //
Stucco Banding (7
Any other stucco features
Accessory Buildings
Other
r
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
s, ples.
/nature of Owner Date Signature of Contractor Date
*********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
WHEN PAINTING IS FINISHED,
CALL FOR FINAL INSPECTION
APPROVED: ,� - p
0
fficial . Date 4/23/01
1
carpi Shores V t�a
10050 N.E. SECOND AVE.
MIAMI SHORES, FLORIDA 33138 -2382 •
Telephone: (305) 795-2207
Fax: (305) 756 -8972
Dear Property Owner:
While making inspections in the area, I noticed the
following items needing your attention:
0 Property is in need of mowing / cleaning
O Trash on site
O Exterior of structure requires maintenance
O Trees /bushes /hedges need trimming
O Commercial vehicle in residential zone
O Inoperable vehicle on property
O Vehicle parked in landscaped area
O Vehicle parking areas must be paved
O Vessel / boat not properly stored
O Interior / exterior work requires permits
O Prohibited signs on property
O Non - domestic animals on property
O Other OCS - /L/ f //-Y
7 ✓
rear �� ,c1 ;KIS Q ! : � /rYw u �� ;
Correc ac ion n eded by:
OP .1 �1 (D)
11/Y11""( C ) , o
C r` �3f'f Sf . ( rte,:52); =�
` l Gt cc
Failure to corrtct the violation by the above date may
result in a Notice of Violation to appear before the
Code Enforcement Board which may impose fines up
to $500 per day. The Village residents have always
taken great pride in the community and we know that
you share in his effort to keep the "Village Beautiful ".
Your copper ti n is appreciated.
(
6 1, 1 h73
Code Enforcement Officer Date
(305) 795 -2204
PERMIT APPLICATION FOR MUNICIPALITIES OF DADE COUNTY
(OWNER TO RETAIN COPY)
er/d ' q 5.7- //��
g Description 41 9L # 4 ;;" ' S �"
Legal Descri tion � Master Permit #
Job Address
Owner's Address? '16.!F
Contracting Co.
Qualifier .///e Q - 4/2'/L
State ii
Architect /Engineer
Bonding Company
Mortgagor
Lessee / Tenant
WORK DESCRIPTION
__Square Ft.._ __
79ze/Ale/&,6
Competency #
Signature of Own= /or Condo President
Date:
Nota
My
*
PERMIT FEE?..-
CC-Y- 1,0
Zoning
Mechanical
SS#
do President
E .pi =e Wm
j * Sifa of Horida a
My Commission Expires March 29,1992
°APPROVED: Fire
. 7
Building
Plumbing
Address
i c
phone
� . c4b) l q1
Tax Folio // d6 3�d/007
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL PAVING FENCE SIGN
phone
Ins. Co.
Estimated Cost —
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. 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.
Signature of Contractor or Owner - Builder
Date:
Notary as to Contractor or Owner- Builder
My Commission Expires:
* * * * * * *
Other
Electrical
Engineering