DS-07-44r
s z
xic.o
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Date: 11/07/2007
Inspector: Rodriguez, Jorge
Owner: CAMACHO, RICHARD AND JOSEPHINE
Job Address: 152 101 Street NE
Miami Shores Village, FL 33138-
Project: <NONE>
Contractor: CHAMPION CONCRETE
Permit Type: Driveways/Sidewalks/Slabs
Inspection Type: Final
Work Classification: New
Block:
Phone Number (305)757-7057
Parcel Number 1132060131980
Lot:
Phone: (305)252-8055
Building Department Comments
BRICK PAVERS DRIVEWAY
A t
\'‘`° -
Passed
-
Inspector Comments
CREATED AS REINSPECTION FOR INSP-36922. No permit available
for inspection. no one home 11/5/07 CG
MLD ill 7 P 7
7
/ i
Failed
Correction
Needed
Re-Inspection
Fee
($75)
No Additional Inspections can be scheduled
re-inspection fee is paid .
until
Tuesday, November 6, 2007
Page 1 of 2
Miami Shores Village p1111do;,
Building Department WI
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT AP ' LICAT N R JAN 1 1 2007 Master Permit No.
‘:: SMIA-
Permit Type (circle : Building Electrical Plumiing Mechanical Roofing
r- 17 G Permit No. �n
FBC 2004
Owner's Name (Fee S' . er) , 1°C 11T P kit C<2O Phone # ;103-- 757-7& 7
Owner's Address �i; E /fy
city /",) m i' 5 pirtT State
Tenant/Lessee Name
zip 35''f2
Phone #
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip 5
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company
Contractor's Address
City
Qualifier Name
ame
A/ �% � C CA' hone # 05 27 2 �05 5
State Zip 3 3 igb
Phone #
State Certificate or Registration No. Certificate of Competency No. C'e�� ®rji'
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: DA
Describe Work
Phone #
Square / Linear Footage Of Work: Z ®(.90 /
Repair/Replace 0 Demolition
******** * * * * * * * * * * * * *** * * * * * * * * * * *** * ** Fees * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * *** * **
1
I...
Submittal Fee $
Notary $
Scanning $y
Bond $ ma
Permit Fee $
Training/Education Fee $
Structural Review. $
• CCF $ ° ). C) CO /CC
Technology Fee $ ?j -12>
Radon $ DPBR $ ` • Zoning $
Code Enforcement $ ;Double Fee $ � ��
Total Fee Now Due $
See Reverse IAN p��a 1
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 asence of such posted notice, the
inspection will n e approved and a r inspection fee will be charged.
/ Z-
Owner or Agent
Signature
The foregoing instrument was ac .y +wledged before me this 19
day of t)v) ,20y!y,b 014�
who is personally known to me or who has produced
CVO 740�—V7 '4 OAs identification and who did take an oath.
NTARY®UBLIC:
\.(,)
Sign:
Print:
NOTARY PUBLIC- i7TE OF FLORIDA
Gisela Basilio
Commission # DD491643
Expires: NOV 17, 2009
Signature
l� Contractor
The foregoing instrument was acknowledged before me this
day ofJ) ,20e6,by //te- 5A-4 d ,
who is personally known to me or who has produced F
t:/11% e %has identification and who did take an oath.
NOTARY PUBLIC:
My Commission Expires:
Sign:
Print: a
My Commission E
APPLICATION APPROVED BY:
(Revised 02/08/06)
Plans Examiner
Engineer
Zoning
iurni -Chore
10050 N.E. SECOND AVE
MIAMI SHORES. FLORIDA 33138 -2382 u 5777
Telephone: (305) 795 -2207
Fax: (3051-756- 8972.. JAN 1 1 L
1�COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY 1 ' 44
WHEREAS, 4-Cal "4 C/} �l V , hereinafter referred to as the Owner of the
(owner)
following described property:
Legal description/folio #:
Lot Block Subdivision
Tax Folio Al:
requests permission to install:
[halt, concrete, brickpavers
[ Landscaping
[) Other C
within the public road right of way of 7 2-- 1V 1= l (7 55-- 11004/1-1,6 Sir -3 3/ ?(
IN CONSIDERATION of the approval of this permit by the Village, the
(address)
Owner agrees as follows:
1. To maintain and repair, when necessary, the above- mentioned item(s) installed within the dedicated right
of way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said
items within public right of way including restoration of street by reason of the Owner's failure to do so,
such expense shall be paid by the Owner or shall constitute a Tien against the above described property
until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores Village or dade County harmless from
any and all liability, which may rise by virtue of permitting the installation of these items within the public
right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days
notice by the Village to do so. Failure to comply with this notice will result in the Village causing the
item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all
costs incurred in the removal and disposal of the item(s). .
4 The undersigned further agrees that these conditions shall be deemed a covenant running withtIie land and
shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such
time as this obligation has been canceled by an affidavit filed in the Public records of Dade County, Florida
by the Village Manager of Miami Shores Village (or his fully authorized representative).
SIGNED, SEALi MIMj -g , ACKNOWLEDGE b OWLEDGE on this' I ..y of
Gisela Basilio
Commission # DD491643
Expires: NOV 17, 2009
Bonded Thru Mende Bonding Co., Inc.
SIGNED. SEALED AND DELIVERED in the presence of
AFFIDAVIT
--STATE OF FLORIDA)
COUNTY OF DADE)
The undersigned Affiant, r aAa if0 64441 0 , does hereby attest that the
(property owner)
attached survey, performed by OA/1 C= S Zit X 7 iNG l /f t
(name of surveyor's company)
performed on 5-2-/- qj , is an accurate representation of the existing conditions and
(date of 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
,g;
2007,
i)� o_0 -®
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 the property which are not
permitted -or which may violate zoning or building code regulations. The Affiant further understands that the
existence of any such structures may affect final inspections as applicable -t • is or other permits..
Further, Affiant sayeth naught.
Couv-cet
t/Property owner
Witness(sign and print)
SWORN TO AND SUBSCRIBED before me this I ti day of i,N)b,, Q. set,ke <, t°
Affiant is personally known to me, .,/produced co So: -140 -in- 4{)7 -c, as identification.
NOTARY PUBLIC -STATE OF FLORIDA
Gisela Basilio
Commission # DD491643
Expires: NOV. 17, 2009
Bonded Thru Atlantic Bonding Co., Me,
NOTICE OF COMMENCEMENT
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION
PERMIT NO. X O'$ � 41 TAX FOLIO NO.
STATE OF FLORIDA:
COUNTY OF MIAMI -DADE:
THE UNDERSIGNED hereby gives notice that improvements will be made to certain real
property, and in accordance with Chapter 713, Florida Statutes, the following information
is provided in this Notice of Commencement.
111111111111111111111111111111111111111111111
CF14 "20 o 6R 1247594
OR Ek 25120 F's 2695; (1 as )
RECORDED 11/22/2006 09 :5Oo05
HARVEY RUV'IPI, CLERK OF COURT
MIAMI —DADE COUi4TYe FLORIDA
LAST PAGE
I k
JAN 1 1 2007 �d
kci
1. Legal description of property and street/address:
a nj ^s- 07,0 40a► $h-1 3313/-
2. Description of improvement: .4 iv -ewAl
3. Owner(s) name and address:
t'2- NL
e-04.0444) CA*1A€ 0
tot o 04,44A 51i144,1 331 r
Interest in property:
Name and address of fee simple titleholder.
4. Contractor's name and address:
30
;HO
•
4b
5. Surety: (Payment bond required by owner fr
Name and address:
Amount of bond $
6. Lender's name and address:
1itof 7 OZ I,4 Kii' i& ; 'DE
, of tii
from contractor, Y CERTIFY that this w tr ': r11;o/
CI mA yr► Ca ti
s^� co
it
ear '- V A
7'NsssAmy hand and Ofiial�
HARVEY RUVIN, CLERK,
3
° co.*
7. Persons within the state of Florida designated by Owner upon whom notices or other documents may be served as
provided by Section 713.13(1)(a)7., Florida Statutes,
Name and address:
8. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided
in Section 713.13(1)(b), Florida Statutes.
Name and address:
9. Expirati ate of this Notice - ommencement: (the expiration date is 1 year from the date of recording unless a
differ ntt e i pecifie
S' ature of Owner ,
Print Owner's Name 7►� r,C ii %4 ?D lfi Y%2i' Cat Prepared by ../f - be'f `e— /7'Sl.--1 c)
Sworn to and subscribed before me this 14- day of %Jei%)C IA4)¢.,- , 20n k0.
- - Address: $337J /'it yr4--r...
Notary Public
Print Notary's Name
My commission expires:
123.01 -52 PAGE 4 8/02
to
ct .
it u tE°J Qa , �► 33/96
Gisela Basilic)
Commission # DD491643
Expires: NOV. 17,c 2009
Bonded TMv Atl»atie RAM ON
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
l Permit No.
PERMIT APPLICATION Master Permit No.
FBC 2004
MOrgEVMa
JUN 2 9 2007
BY:_
so-7—A4
Permit Type (circle):
Owner's Name (Fee Simple Titleholder) ill / ( --
Owner's Address /
City /t // J) ,ra c S h ri}
Electrical Plumbing Mechanical
Tenant/Lessee Name
Phone #
- 7
Roofing
State /` L
Zip 3 r_34
Phone #
Job Address (where the work is being done)
/L�' /' S/
City Miami Shor s Village County Miami -Dade Zip 3 P' -4'
FOLIO / PARCEL #
Is Building Historically Designated
Contractor's Company Nanie
Contractor's Address
City
Qualifier Name
YES NO
-bwkcb 000/r
Phone #
State
Zip
Phone #
State Certificate or Registrat
Architect/Engineer's Name
on No. Certificate of Competency No.
if applicable) Phone #
Value of Work For this Permit $ ( UCH
Type of Work: ['Addition ['Alteration
Describe Work: •F4%
Square / Linear Footage Of Work:
['New
[� Repair/Replace
0 Demolition
* * * * * * * * * **
* * * * * * * * * * * * * * * * * * * * * * * * * ** Fees****+******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ �� CCF $
Notary $ T • ining/Education Fee $
Scanning $ Radon $
Bond $ Code Enforcement $
Structural Review. $
�—° Technology Fee $
DPBR $
Double Fee $
CO /CC
Zoning $
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 att chment. Also, a certified-copy of the recorded notice of commencement must be posted at the job site
for the first inspect" hic occurs seven 7) days after the building permit is issued In the absence of such posted notice, the
inspection will nco`15 app" ved and a ctio fee will be charged
Signature
Signature
Owner or Agent Contractor
The fore ()ling instrument was acknowledged before me this .1 The foregoing instrument was acknowledged before me this
day of l'Q, ,2( ,by!� %�y(� CiiioZ l day of ,20by ,
wi. isp
1101
rsonally known to me or who has produced
NOTAR
Sign:
Print:
My Co
As identification and who did take an oath.
C: �.,.�..T,pAUB
r°'a.si0
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
vafo,
Y
-13,20 )� rint:
o� At My Commission Expires:
sion Expires:
APPLICATION APPROVED BY:
(Revised 02/08/06)
Plans Examiner
Engineer
Zoning
VILLAGE OF MIAMI SHORES
OWNER BUILDER DISCLOSURE STATEMENT
NAME: V t i)/ J / 0'j-/)/ /1 //L ' • DATE: 6 U
, � � f
f
ADDRESS: A -
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws
of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure
statement, which entitles me to work as my own contractor; I further understand that I as the
owner must appear in person to complete all applications.
State Law requires construction to be done by a licensed contractor. You have applied for a
permit under an exception to the law. The exemption allows you, as the owner of your property,
to act as your own contractor even though you do not have a license. You must supervise the
construction yourself. You may build or improve a one - family or two- family residence. You may
also build or improve a commercial building at a cost of $25,000:00 or less. The building must be
for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a
building you have built yourself within one year after the construction is complete, the law will
presume that you built for sale or lease, which is a violation of this exemption. You may not hire
an unlicensed person as a contractor. It is your responsibility to make sure the people employed
by you have licenses required by state law and by county or municipal licensing ordinances. Any
person working on your building who is not licensed must work under your supervision and must
be employed by you, which means that you must deduct F.I.C.A and with - holdings tax and
provide workers' compensation for that employee, all as prescribed by law. Your construction
must comply with all applicable laws, ordinances, buildings codes and zoning regulations.
Please read and initial each paragraph.
1. I hold title to the above property and I am planning on doing this construction
Initial Y` (
2. I understand that as an owner- builder I must abide by all zoning ordinances and
building regulations in effect at the time of permit application
Initial
3. .I have an understanding of the 2004 FBC & FRC and understand that this
department and its inspectors are there to help enforce and interpret the code.
There is a copy of the code in this office for review.
Initial
4. I understand that the building official and inspectors are not there to design,
alter or give advice on how to meet code -. only if the structure meets the
minimum code.
Initial
5. I understand that as an owner - builder, that any contractor disputes with sub-
contractors and myself must be handled in a civil court with the advice of an
attorney. The department will not mitigate'any contract disputes.
Initial r'(
6. I understand that if I compensate any person or company for work performed
they are required to have a business license in the county. If for any reason they
do not posses a business license I will be responsible and liable for any wrong
doing from this unlicensed company or person.
Initial
7. I understand that if any person gets injured on my construction project—they are
entitled to workmen's compensation. And if they do not posses a workmen's
policy I could be held liable for all doctor and related cost which could include
loss of wages during recovery from injury.
Initial
8. I understand that under state and local laws I can not do any Electrical,
Plumbing, Heating, Air & Roof work on my property with out first obtaining
the proper permits by licensed contractors.
Initial
Was acknowledged before me this day of 20 (
By IJALI A aittaGlo who was personally known to me or who has
Produced there License or [110—„ t9(09
OWNER
as identification.
NOT
,•
,;: ,..,YPUBiIbel F •
Vargas
= Commission #DD679170
soiv�EOr�le. „„ ,1 Expireso ' .NLY 13, 2011
a Bonin co, INCA
AIWA
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204 Fax: (305)756 -8972
Permit NO. DS -6 -07 -1371
abs
........................
........................
Issue Date: 7/5/2007
Expires:7 /5/2007
Folio Number:1132060131980
Owner's Name: RICHARD AND JOSEPHINE CAMACHO
Owner's Phone: (305)757 -7057
Job Address: 152 101 Street NE Total Square Feet: 0
Miami Shores, FL 33138-
Total Job Valuation: $ 1,000.00 •
Contractor(s) Phone Primary Contractor
HOME OWNER Yes
Planning and Zoning Criteria and Comments
Approved: No
Comments:
Date Denied: 7/6/2007
PROPOSED DRIVEWAY REPLACEMENT DOES NOT MEET VILLAGE CODE REQUIREMENTS
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305 ) 756.8972
Permit No. &7- /3-7
Job Name A- MA-CA®
Date
BUILDING CRITIQUE SHEET
X C s ®DlI4 v¢t) >S 40-1-#=/
::4AiAJ h p mat A- ! / ,4i 2. /-€'2f t\T A04-[•�
M2i2cOs to ' ,A-0
Reviewer:
Claudio Grande C.B.O
305 - 795 -2204 Ext 1430
iumi Sh.oNeo ?Aiap •
10050 N.E. SECOND AVE.
MIAMI SHORES, FLORIDA 33138 -2382
Telephone: (30.51795-2207
Fax: (305)756 -8972.
+ p
OVENAN F CONS RUCTION WITHIN RIGHT OF WAY
WHEREAS, (I C VIAW �'���, / C ) , hereinafter referred to as the Owner of the
(owner)
following described property:
Legal description/foliog:
Lot 7 f
Tax Folio R:
Block / Subdivision
requests permission to install:
[ Asphalt, concrete, brick pavers
[3] Landscaping
[] Other
within the public road right of way of /f - ' 4'> >'' J/
(address)
IN CONSIDERATION of the approval of this permit by the Village, the Owner agrees as follows:
I. To maintain and repair, when necessary, the above- mentioned item(s) installed within the dedicated right
of way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said
items within public right of way including restoration of street by reason of the Owner's failure to do so,
such expense shall be paid by the Owner or shall constitute a lien against the above described property
until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores. Village or dade County harmless from
any and all liability, which may rise by virtue of permitting the installation of these items within the public
right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days
notice by the Village to do so. Failure to comply with this notice will result in the Village causing the
item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all
costs incurred in the removal and disposal of the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant running with•the land and
shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such
time as this obligation has been canceled by an affidavit filed in the Public records of Dade County, Florida
by the Village Manager of Miami Shores Village (or his fully authorized representative).
SIGNED, SEALED, EXECUTED AND ACKNOWLEDGE,on this
� day of Jit 4- >�,
. (owner)
SIGNED, SEALED AND DELIVERED in the presence of:
Planning and Zoning Criteria
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204 Fax: (305)756 -8972
Permit NO. DS- 1 -07 -44
Folio Number:1132060131980
Owner's Name: RICHARD AND JOSEPHINE CAMACHO
Job Address: 152 101 Street NE
Miami Shores Village, FL 33138-
Owner's Phone: (305)757 -7057
Total Square Feet: 1000
Total Job Valuation: $ 6,000.00
Contractor(s)
CHAMPION CONCRETE
Phone Primary Contractor
(305)252 -8055 Yes
Planning and Zoning Criteria and Comments
Approved: Yes
Comments:
Date Approved: 9/25/2007 : Yes
BUILDING
PERMIT Al
FBC 2004
Permit Type (circl
Miami Shores Villa
Building Departme
10050 N.E.2nd Avenue, Miami Shores, Florida 3
Tel: (305) 795.2204 Fax: (305) 756.8972
0'42 mil.
PLICATION JLMaster Permit No.
Permit No. 5 -03- I
Roofmg
Owner's Name (Fee Sirhple Titleholder, /24 C1'/'
Owner's Address /5". Ale ?� // 5
a Phone #
City i ) It tL State
Tenant/Lessee Name
Zip 3 i /i',
Phone #
Job Address (where th
City Miami
FOLIO / PARCEL #
Is Building Historicall,
work is being done)
hores Village County Miami -Dade Zip
Contractor's Company
Contractor's Address
City 114 w 5
Designated YES NO
,�.� 2S2 edsir-
Name °, � �t �r��� l� �-0 /�'�l �, Phone # 3�
(33O s f'krt7r#/L
Qualifier Name
State Certificate or Registration No.
Architect/Engineer's Name (if applicable) Phone #
State
Zip 339 ff
Phone #
Certificate of Competency No.
Value of Work For thi Permit $ Square / Linear Footage Of Work:
Type of Work: ❑Addition
I 0
Describe Work: ; ✓� V
Alteration
['New
❑ Repair/Replace
❑ Demolition
Submittal Fee $ Permit Fee $ ° CCF $ CO /CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ $ Zoning $
Bond $
Structural Review. $
Radon $
Code Enforceme $ — , I otble Fee $
"% dotal Fee Now Due $
OCT 1 2007
tiH
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 $25001 the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be de, ivered to the person
whose property is subject to attachment. Also a certified copy of the recorded notice of commence ent 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 s ch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature 1
Owner or Agent
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this C <'`fi
Contractor
day of , 20 _, by day of j , 20 (' , by P ^ 6 1tr,! s , "a
who is personally known to me or who has produced who is.p so, onal_ y known to me or who has produced
As identification and who did take an oath. as identification and who did an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
- °'o4, 01) :1 a
Sign: Sign:
Print: Print:
My Commission Expires: My Commission Expir
* * * * * *** **,x** ** :********* : ** *:x**** * * * *** x* ***** * * * * * ********* *** ***** ** * ***** ****,x*:x** * * ****:x** ** ****a ***
APPLICATION APPROVED BY:
(Revised 07/10/07)
1,)-cfrA
Plans Examiner
Engineer
Zoning