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OCCUPANCYN° 133 CERTIFICATE OF OCCUPANCY MIAMI SHORES VILLAGE, FLORIDA BUILDING DIVISION J Miami Shores Village, Fla., . f - Owner, Agent or Tenant of Building de Lot Block r'' Subdivision Street Address Approved use by occupancy Remarks This Certificate of Occupancy is issued to the above named for building at above named location only upon the express provision that the applicant will abide by and comply with all conditions of Ordinances Nos. 92, 93, 94 and 97, known as the Zoning, Electrical, Plumbing and Building Ordinances of Miami Shores Village pertaining to the erection, construction, alteration or remodeling of buildings or structures. • BUILDING DIVISION - 69' /444,. LZ 4 )%i: • Suleivision 4 0. Number • Block Street -42"/ J ,iliJ' Owners 0 41". -Name- - No. •- -Address or _Phone - Contractor - Lie. Address or Fhorie .• Zone R eq • Cu. Ft. 2 4 ,! ( - Cx...b.Cout. By Ic; Plat Irestrrdtion *Chkd: 46 To Planning-Board ,f9 p- Apg ;"fr- '2;1. Li .(\ "Re j acted Re-Submitted to: P.Bd. Approved Rejected Plan & Sped.. Checked by Date To 'Came ApproVed ' Rejected Bldg. Permi NO...t. / ' Date, g ee / < . - Cost ';'' i a 0 Type C ....._ f 2 ,.._-..... - - - ----- Stories . ';',..t?...:.? ---• -- " • -.:- Roof / . New . CORS t rIlet-ibrl"-: --- :- ' . - • , A1 - teration,.1,' 4. ' - - Repair, • ..• -__ Permit...No'. j_-2- /2'.`,. Date ,---/Z^.11/0 . Septic Tank ...-- ...1 . "//-/2 4 -ler 0 S New Const. Alteration . . .. ...Repairs . • 1! ziee-yo IT • , ..• ' 2 „, 0 • 1 Electrical Permit No. /4/ ,1 �.' Date ii.. 4- 4+ F* Fee ':: Fixtures ir 3 Heater it if Motors tt tt taiSce1. 11 3 law CoTIst, Alteration Repairs i,a In"T. Lake - - By 'n=a by Reinsp. 13 Foundation i BGaas & Lintels / 4- . 1/4 O`4 Final _ / i / ,/ .4 . • Final Clan -Up / // ,/ /a-ys , r , Plu Isp. Date itouhing f,1 ,t3' - ,S 1 D Fixtures f/ /, • - /1 Sewer %/ --"?€2 Septic Tank if-ti-4(e2 Solar Heater ,//- /...9--0!/, Final Ccrt, El r ;Lt, yi �. Insp . RuuF,h Fixtures -- Final Service . K. to Power Co By Re- -Insp. By Reinsp. By Date By V Stn ) A7( Re -Insp. By Reinsp. By PAID BY YEAR / ANNUAL TAX PERIOD USED AMOUNT PAID DATE PAID RECEIPT NUMBER 1940 J[% m / _ .70 1941 / mo d �12 / /Y 6_ ' p. s40r i 1 0 1942 d 00 — / nC 3 4,r // • l / / 1943 /0 ' 0 ` /7- t 5 0,7 . i) / , / / � ,� 1944 /Q. C/U �/�� 10�3(� d 7 . ( • ( 1945 Al . 0"t' f ,.ie.. 'S -2/ es/ R . 1946 1947 ,Q. 11. Q a ,4-a -4/ >,----/1,--)t7 S1/45. a7 77 ,',_— F •- yek i .0 • / i 7 - ` / f r // 2 ' 1949 / � -/- W .5� '' �' ' f /fff / 7 93 D- 1f �, �, 19 50 ,, /f- ..3/- .5V '' ...1- 7 se LOCATION 1263 N. ;:,. 101st. St. ,5 „ GARBAGE TAX RECORD 1263 N. E. 101st St. by year annual tax period used amount paid da,e paid receipt # /2 . a *- T. .7. Harris /f-5/ BUILDING ELECTRICAL PLUMBING Owner of Building z� MIAMI SHORES VILLAGE, FLORIDA PERMIT N? 1201 Architect _ e w, Contractor or Builder gal Lot 1 .4 7 rt Description Work to be performed under this Permit 4 Address of Building ! �✓ r ° Subdi- vision h DATE 194 Contractor's License No. / Value of r Amt. of Project j ♦ 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 dr .drawings or in the statements or gpecifications and that he assumes responsibility for work done by his agents, servants or employees. 1 +' t w Signed: (,,,,,,/, // do / . / f., .. 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 regula- tions 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. CeeesillOnbe CONTRA C➢ dR OR BUILDER BY 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 regula- tions 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. i . 0 ' `�, Date — — — , 19 ' s. a No.41 r 3 S Street,VtV Registered Architect and /or Engineer_ __ ___— __ ___ - - . af""a ��' Name and address of licensed contractor / / `s'> ,, ,... )i ' ,^V <". cM . ,° ' a'' . P° ' >' ,: > q , / 4: MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMIT Location and legal description of lot to be built on: . s Lot____�!r_____— ______ Block_ -' £ `I ______ Subdivision Street and Number where work is to be done____ 2__132 / State work to be done and purpose of building (by floors 7 r' _and for no other purpose. New Building Remodeling Addition Repairs No. of Stories To be constructed of e ` Kind of foundation___ 4 : , e ' ' ' i' F e /c _Amount of Permit $ Estimated Total cost of improvements $___ it _Roof Covering___________!%° °fit= Zone cubage required_ Distance to next nearest building "';',e 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 J'// `4 e a; l `!`� �` — - -- - �`��' �� f��G � . �A 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 work such public notice or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performed under this permit, as are licensed by Miami Shores Village. . l � to Remarks STATE OF FLORIDA, COUNTY OF DADE. ss. Permit No. mod (Sign Buil Cha' Member Council o . roved D G BOARD Date Ne : A charge of $1.00 will be made for making corrections the Planning Board. A re- inspection fee of $1.00 will be charged when such re- inspection materials and /or workmanship. (over) Member Member Member w e d .5 d • /4 g . - 1)- eco t, f • 9 Read, Sworn to and Subscribed before me. Notary Public, State of Florida ommission Expires ________________ —__ DATE 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 fpregoing application, and that he did sign the same, and that all facts therein by him sstt to j, are true. Disapproved -------- ----- ----- ---- -- - - - -- ------ -- ------ -Date or changes to this application after approval has been obtained from is made necessary by improper notice for inspection or faulty LIST OF CONTRACTORS, SUB - CONTRACTORS, ETC. REQUIRING OCCUPATIONAL LICENSES MIAMI SHORES VILLAGE 1. General Building Contractor. 2. 3. f`i; Plumbing, Hating, Ventilating, Air Conditioning and Gas Fitting. Electrical. 4. Architects, Engineer, Surveyors, Landscape Architects and Interior Decorators. • 5. Excavating, grading, filling and Landsca qs 6. Moving or wrecking. 7. Septic Tank and Drain Field. 8. Brick, Stone, Tile, Cement Block, Concrete 9. Carpentry, Millwork, Awning and Shutters. 10. Cement, Lime, Plastering, Stucco, Lathing and Cast Stone. 11. Decorating (interior and exterior), Painting, Waterproofing, Damp- Proofing and Paper- hanging. 12. Flooring, sanding ors finishing; wood, rubber, composition, linoleum and other flooring not otherwise specified. / / c , 13. Ornamental Iron, Bronze and Steel, Steel Sash, Over -head Doors. ,4 .. � 14. Roofing, Sheetmetal and Sk fl ights. 15. Solar Water Systems. v and Gypsum. 16. Well drillers. : 17. Sprinkler Systems of all kinds, including those for Buildings, Lawns.... 18. Structural and Reinforcing Iron and Steel. 19. Tile, Terrazzo, Marble, Granite and Cut Stone. 20. Electric Fixtures. 21. Illuminated Signs. a 22. Bridge, Bulk- heading, Drainage Sewer, Water and Gas excavation and Construction, Dredging, Irriga- tion System, Pile Driving, Sea Wall, Paving, Sidewalks, Curb and Gutter or similar work. 23. Every person, firm, co- partnership, Corporation, Association or other organization engaged in the bus- iness of supplying, furnishing or delivering building materials for any construction project within the Village Limits and not having a regularly established and licensed place of business in the Village. (Rev. 10/02/03) RE- OCCUPANCY APPLICATION Date 1'/ /o Contact Name .pup "( Buyer Seller t/ Realtor Company Name Property Address / I. 3 t.1 E / 5 City Miami Shores NOTARY PUBLIC: Sign: Print: My Commission Expires: Miami Shores Village Building Department mOV 2 BY --11' State Fl Loc ID Permit No. OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate. Applicant Name \JO y Sf/�nl�D Signature Building Officials Approval: 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795 -2204 Fax: (305) 756 -8972 gG00 4 Phone # Zip 3.31 I hereby certify that I understand that the zoning of the property is for single - family residential use and that it is unlawful for more than one family to reside therein. I also understand that any Certificate of Re- Occupancy that may be issued by Miami Shores Village certifies only that the referenced property is being used for single - family purposes and that such Certificate does not constitute any representation, warranty or certification as to the condition of the dwelling or other structures on the property. The or going instrument was acknowledged before me this 0- day of I \/rnJ( , 20 _, by )" V' S1aT1)1OLA , who is personally known to me or who has produced � ''4 1 5 I -' 4 4 4" ( ication and who did take an oath. Re -Occ. $60.00 Y Notary $5.00 \ CCF $0.60 \, Total • IN THE CIRCUIT COURT FOR MIAMI -DADE COUNTY, FLORIDA PROBATE DIVISION IN RE: ESTATE OF PAUL W. SHANNON, Deceased. LETTERS OF ADMINISTRATION (single personal representative) TO ALL WI -10M IT MAY CONCERN • ..f. a WHEREAS, PAUL W. SHANNON Miore$Vliami -Dade died on July 7 2006 owrunijse t in the State of Florida, and 'REAS, JUDY SHANNON appointed pe sorial of the estate of the decedent and has erformed has been prerequisite to issuance of Letters of Administration in the estate, p all acts NOW, THEREFORE, I, the undersigned circuit judge, declare JUDY SHANNON duly qualified under the laws of the State of Florida to act as personal representative of the estate of PAUL W. SHANNON deceased, with full power to administer the estate according to law; to ask, demand, sue for, recover and receive the property of the decedent; to pay the debts of the decedent as far as the assets of the estate will permit and the law directs; and to make distribution of the estate according to law. IN THE EVENT FLORIDA REAL ESTATE IS SOLD, THE NET PROCEEDS OF SALE SHALL BE DEPOSITED IN A COURT ORDERED DEPOS;TORY PER F.S.69.031 INVENTORY SHALL BE FILED WITHIN 60 DAYS THIS ESTATE MUST BE CLOSED WITHIN 12 MONTHS IF NOT C ONTESTED, File No. Division 06- 3160 03 STATE OF FLORIDA COUNTY OF DADE cuit udge Jiuciye Maria M. Kvrvick THFSE LET rERS CO t IOT AUTHORIZE • 11ir SALE. ENCUMBRANCE OR BORROWING OF ANY ASSETS WITHOUT SPECIAL ORUER OF TIE COURT 1, THE UNDERSIGNED, Depu County, Florida, DO HEREBY CERTI Is a true and correct copy of the record and file in this office of the Circm Florida, and that same is In full force and Effect.. WITNESS my • s. and Seal of th; Circuit Court at Miami, Florida, this 1 or AA.20 rk, C' IA t/ is utv a . Court a resident of STATE OF FLORIDA 1. DECEDENT'S NAME (Feel, Muddle. Las( Sudto) 6 SOCIAL SECURITY NUMBER 099 -22 -7150 12. MARITAL STATUS (Speedy) - Married _ timed. but Separated 110. STREET ADDRESS 1263 N.E. 101ST STREET PRINCIPAL _ OFFICE of VITAL STATISTICS CERTIFIED COPY FLORIDA CERTIFICATE OF DEATH 32. TIME OF DEATH (ill a.) 2230 PAUL W. SHANNON ea. AGE -Last Birthday 10. UNDER 1 VEf7 ac. UNDER 1 rY (Years) 75 Monts ay, Moore Minutes 7. BIRTHPLACE (Dry and Stem or Finaign Country) BROOKLYN, NEW YORK _ 01(106art _ Emergency Room0rnWtiar0 _ Deed on *rival NON•HOSPITAL: _ Hospice Facility _ Nursing Nornarlo'9 Term Care Focally ! Decedent's Home - Oder ( Speedy) 10. FACILITY NAME (d not institution. give areal .doss) 11a. CRY, TOWN. OR LOCATION OF DEATH 1263 N.E. 101ST STREET MIAMI SHORES • X Widowed _ Divorced _ Never Monied 146. COUNTY MIAMI -DADE 15a. DECEDENTS USUAL OCCUPATION (Indicate type of work Acne during mast d worwW We.) • Co not use named' 8. COUNTY OF DEATH MIAMI -DADE 13 SURVIVING SPOUSES NAME (d aa a. *a maiden name) 'N /A .. 14c. CITY TOWN. OR LOCATION MIAMI SHORES 14e. APT. NO. 156. KIND OF BUSINESS/INDUSTRY ELEMENTRY 141. DP CODE 33138 16. DECEDENT'S RACE (Speedy IM racarraces b indium nnat decedent csinsd re4 himself/Waal b o.. More den one race may o. epecias0.) carte _ Black or African American _ American Indian or Alasean Native (Speedy trio.) _ 60.eul :mean _ Chirasd. _ FT puce _ Japanese _ Kaman _ Vietnamese _Oder Asian (Speciry) Native Hawaiian _ Guamanian or Chamorro _ Semen _ Omer Pectic Ica. (Speedy) _ OtNo (Specify) :7, DEC :JENT OF HISPANIC 0'F. r1AiT:,`.:: _ ..... _Yes (d Yes. spec+b) X No _ Mexican Puerto Rican Cotten CeniraVSoum AmeriAmerican (Specify r decedent nos of Hispanic or Helen Om.) _ goer Hispanic (Speedy) 16. DECEDENTS EDUCATION (Speedy the decedent's highest degree or 0400 d edbd complete 0 a ems d death.) _ Stn or less _ High school tot no diploma _ High sdbol diploma or GED _ College 6N no degree College degree (Speedy): _ Anodes BAGlotor's X Master's _ Oosorate 21. MOTHER'S NAME (Rrs1, Middle. Maiden Swarm) HELEN McGRATH 20. FATHERS NAME (Fist Middle. Lest. SOU) CHARLES EDWARD 22a. INFORMANTS NAME JUDITH 230. CITY OR TOWN MIAMI 266.1F CREMATION. DONATION OR BURIAL AT SEA. WAS MEDICAL EXAMINER APPROVAL GRANTED? _ Yea _ No 296. CITY OR TOWN MIAMI 360 CITY OR TOWN 226. RELATIONSHIP TO DECEDENT SISTER -IN -LAW 23c. STREET ADDRESS 901 N.E. 84TH STREET 27a. LICENSE NUMBER lot Licensee) 1638' 259. LOCATION • STATE 29c. STREET ADDRESS 10931 N.E. 6TH AVENUE 239. INFORMANTS MAILING - STATE FLORIDA , 256. LOCATION - CITY OR TOWN 2. SEX • MALE 110. INSIDE CITY UllaTS7 Yes ' _ sc 14g. INSIDE CITY L1Mu 57 X_ Yea _ac 19. WAS DECEDENT EVER IN • U.S. ARMED FORCES? 33161 N. PLACE OF DISPOSITION (Name d Cemetery. crematory. or Omer place) OUR LADY OF MERCY CEMETERY FLORIDA MIAMI 26a. METHOD OF DISPOSITION X 8uri,t _ Entombment _ Cremation Donation _ Robval from See Other (SpecrT() 276. RAL SE y E ENSEE PERSON ACTING AS SUCH 26. NAME OF FUNERAL FACILITY - 29a. FACILITYS MAILING - STATE COFER - KOLSKI -COMBS FUNERAL HOME FLORIDA , 290. DP CODE JO. CERTIFIER: - CertOying Physician • To the pest of my knowledge. death occurred at Oa bee, date and place. and due to dew cease) and manner sated. (Check wndr Medical Learns ar - On 4249 Oasd ud saer^` ardor irves6pation, it my op0nlai. death occurred at the toe. Oat1 and place. due a 1M causs(1) and mariner slated. 310. (Signiors end 17th W • m -) 310. DATE SIGNED (nuniddr y7yl 33. MEDICAL EXAMINERS CASE NUMBER 349. UCENSE N •'T (d Csnteq 316. CERTIFIER' E 35. NAME OF ATTENDING PHYSICIAN (d Mier Than Cache) J � d z pr.;% / 36d. 2IP CODE f 230. DP DOOE . 33138 e c JUL 18 2006 THE ABOVE SIGNATURE CERTIFIES THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE. THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH A WATERMARK OF THE GREAT WARNING: SEAL OF THE STATE OF FLORIDA ON THE FRONT, AND THE BACK CONTAINS SPECIAL LINES WITH TEXT AND SEALS IN THERMOCHROMIC INK DH FORM 1946 (08.04) ./ 99P2P0 P. 1 1 11 1 11 11 1 1 ' FILE RETURNED TO: INITIAL Miami Shores Village Building Department 10050 NE 2 Ave, Miami Shores, Fl 33138 Tel: (305)795 -2204 • Fax; (305)756 -8972 PLEASE PRINT DATE: (2.S 1 TIME: NAME OF PERSON REQUESTING FILE:C ) ` Y (-- C�) PHONE #: YOUR ADDRESS: i. ° D a 3 4--- ADDRESS OF FILE REQUESTED: \ 2 ( 1 t- 0 ` S INFORMATION REQUESTED: - I understand that all documents in this file are property of Miami Shores Village and that NO documents may be removed from this file. You may get 4 complementary copies (8x11) size, additional copies will be furnished at 0.15 cents per page, not including any blue prints. If blue prints are order please be aware that we are not responsible for the quality of the printed documents. Acknowledged by: DATE: j 0 ' Z? NAME OF PERSON REQUESTING FILE: PHONE M Z3 I v YOUR ADDRESS: TT- 52- ADDRESS OF FILE REQUESTED: INFORMATION REQUESTED: I understand that all documents in this file are property of Miami Shores Village and that NO documents may be removed from this file. You may get 4 complementary copies (8x11) size, additional copies will be furnished at 0.15 cents per page, not including any blue prints. If blue prints are order please be aware that we are not responsible for the quality of the printed documents. Acknowledged by: FILE RETURNED TO: INITIAL Miami Shores Village Building Department 10050 NE 2 Ave, Miami Shores, Fl 33138 Tel: (305)795 -2204 • Fax; (305)756 -8972 PLEASE PRINT TIME: 12643 ( sr paa-t- //,„0 7.2(,3 7°( %a 7 - Place Village Hall m. Country Club m. Country Club i.m. Country Club Country Club m. Country Club Country Club • :00 a.m. Country Club p.m. Country Club 1 Country Club m. Country Club .m. Community Center MIAMI SHORES VILLAGE, FLA. JOB (4 b � y2/ a 22�fry�a ADDRESS /` 7 `v e INSPECTION TIME READY REMARKS- INSPECTOR 9°S /-- 0 9/ N_ 90 // 8/ DATE 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. 7 Date_ __..._.. Owner's Name and Address._. _ _DorQ thy___Ca �xl _ No Regls Architect and /or Engineer... _ _ . . .. _ .. Name and address of licensed contractor -__. ._.. _.. Ttuly Nolen Inc.. W. -.. -7 Ave - - Location and legal description of lot to be built on: Lot__ Block_________ ___________ _ _____ _ Subdivision Street and Number where work is to be done State work to be done and purpose of building (by floors) -- 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 $ ----- 255.0G Amount of Permit $ ...DD 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 foi said building. All notices with reference to the building and its construction may be sent to _____ _ _ __ The undersigned applicant for this building permit doc 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 work such public notice or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performed under this permit, as are licensed by Miami Shores Village. Remarks • (Signed)_.I STATE OF FLORIDA, COUNTY OF DADE. ss. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap- peared 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 L. 7 _ S 7- / 7 Disapproved _ __ __ _ ( Signed) ____1�L/ _/ Notary Public, State of Florida Council Approved Buildin nspector Fumigation, My Commission Expires__ PLANNING BOARD__ __ . DATE Chairman Member Member _ Member _ Member . Member to me well known, 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. L Location of building to be fumigated 4. Is entire building to be fumiguseu Yes 10. Date whem fumigation will be begun APPLICATION VIKANE X FOR PERMIT TO FUMIGATE WITH CYANIDE METHYL BROMIDE ACRITET APPLICATION NO. DATE 19 2. Name and address of owner of premises Dorothy Cain 3. Type, size and construction of building CBS - Residence /= 2 N. F trPet, Miami Shores S. If not, state what portion 6. Approximate number of cubic feet of space in building or in portion to be fumigated. 28,000 7. Kind and quantity of fumigant to be used and manner of application and length of fumigation period 9. In what manner will vents to exterior of building be sealed? Vikane - Approx 20 hours 8. Distance of nearest building and direction from building to be fumigated nver ID ft Nylon tent May 17, 1967 Time 10 :30 A.M. 11. It is hereby agreed to station a guard on the premises to be fumigated during the fumigation period and to post suitable placards at each entrance into the building bearing the following words in letters at least two inches by one inch in size: "DANGER" — THIS BUILDING UNDER FUMIGATION WITH A DEADLY GAS." 12. It is hereby agreed to make such provisions that all openings into the building may be opened from the outside after the period of fumigation is over and to take such other precautions as may be necessary to insure that all of the fumigant is removed from the building before anyone is permitted to enter. 13. ft is hereby agreed to notify the County Health Department when the building has been prepared for fumigation. FIRM NAME: TRULY NOLEN, INC. 600 N. W. 7th Avenue �\ c Miami 36,. Florida BY (Signature of certi�,ed pest control op rotor 'n charge of this fumigation lob.) 9liksR8 JOB: BUILDING PLUMBING • • • • ELECTRICAL : : : Inspector's Report: : WORK D E BY L • 4,r • • • INSPECTION WAS MADE • : • • : • • The following is ready for Inspection: - : : • • • 7 : WILL BE READY • , NOTE: REQUESTS FOR INSP IONS MUST BE MADE BY THE CONTRACTOR PERFORMING THE WORK.