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BPP-11-1316Permit Number: BPP -7 -11 -1316 I Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 164065 Inspection Date: September 01, 2011 Inspector: Dacquisto, David Owner: WOOLIN, RACHEL Job Address: 489 NE 95 Street Miami Shores, FL 33138- Project: <NONE> Contractor: MARS POOLS Permit Type: PoolslWhirlpools/Hot Tubs Inspection Type: Survey Final Work Classification: New Phone Number Parcel Number 1132060140640 Phone: (954)214 -2844 Building Department Comments NEW INGROUND POOL AND TUMBLED MARBLE PAVER DECK GI_ 1L1 - L I (D) 74/7/ Passed Inspector Comments 91(0 l'I Mk\Z-C...• Failed Correction Needed Re-Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until ("1 �• For Inspections please call: (305)762 -4949 September 01, 2011 Page 1 of 1 5582 N.W. 7th STREET SUITE 202 MIAMI, FLORIDA 33126 TELEPHONE: (305) 220 -3171 FAX: (305) 264-0229 DRAWN BY: TULY /ARY/LILY runt uruPj.arZ slur. LAND SURVEYORS SURVEY No. 5-0007557 -6 SHEET No. 2 OF 2 BOUNDARY SURVEY SCALE =1" : 20' SURVEY ENCROACHMENT NOTES: A)NORTH SIDE OF PROPERTY UTILITY POLE AND OVERHEAD UTILITY LINE ENCROACHING ONTO SUBJECT PROPERTY. 8.17 30.00' 0.50' CL'. 27.58' A/C.ELEV. =9.15' LOT - 23 BLOCK - 53 4.15' LOT - 24 BLOCK - 53 ONE STORY RES. #489 9.69 F.F.E.= 11.50' GARAGE ELEV.=9.0 34.43' 15.15' 0.90' CL. 27.02 16.85' (n °D 17.60' 34.60' F.N.D 30.00' F.I.P 1/2" NO CAP ftUtiAC`Iage B.C. F.I.P 1/2" ZONING DEPT SUBJECT TO COMPLIANCE WITH ALL FEDERAL STATE AND COUNTY RULES AND REGULATIONS 4 SUR , OR There, • ay rents recorded in the Public Records not shown on this Survey. 5582 N.W. 7TH STREET, SUITE 202 MIAMI, FL 33129 TELEPHONE: (305) 284-2880 FAX: (305) 2840229 DRAWN BY: Nova Surveyors, Inc. LAND SURVEYORS SURVEY NO 5- 0007557 -6 SHEET NO 1 OF 2 SURVEY OF LOT 23-24, BLOCK 53, OF MIAMI SHORE SECTION NO. 2, ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK 10, PAGE 37, OF THE PUBLIC RECORDS OF MIAMI -DADE COUNTY, FLORIDA. PROPERTY ADDRESS: 489 NE 95 ST, MIAMI SHORES, FL 33138 FOR: RAQUEL WOOLIN LOCATION SKETCH Scale 1" = NT.S. S -H . 0 -�-�R . C• . L . ©,...N - -D---I • 15 v -D rocs -FF, •I »T.-�- "I "I"°I«- 803°�..I „: »r- i.`- '- T- 1seiner.Ta /yep- t«T-�sarna.s .'. 1 10 l 8 % ' b 1 .' 4 * J � 2 J l ' 41PI 0; 10, 1 1 6 1 % 1 6 1 5, .1 E J, P l 114u Ir4161 .S •t . J 1 .' I, I 1 61. I 1 1 ! I I , g P 1 L 1 f 1S !D I% /D /9 P� LI NiR (1;,. 7,J(I!4 /S /6. IJ 1; 18 � 1) I POI I'r 8110i .81it < ;N 7 .9 9 * 10 `4 1 • l i ► ... :, -891 ' I - 1.... , .. �o:t4' 30l • soy es 7eJ •iib+ S T s ,44., 'ewe. et Sgcl ,s +e SO i T -JO 111;1) in /6t/ h / '� /0•u. r m•4* `: .r3 �.: b 6S'•Id 1,[• - 631 I .. 4 - - .. .. 19. ,M ttt! !tI /e, 9'x.9' ?I 6'.5'1 Fi 3 c' I, 1h a ! .J.1.I..;� *I 1-T -t I ,( r l- 1 ca :1 14 /5 t e ;: e7 • t,9 18 I TO 11 tR �:.1 I'N i ' .1 - 90151, 94T” S T I , -VI 1 .. - I 190(S/8 4 e;It4 /aI 9 a' 6 3 *141 i 4Ili n' ,e' 91 a 7 1 / ! 4 N E. "77T" so�51a lISi 41 31P11� UI III1 JI s I -� .... I- ABBREVIATION AND MEANING A =ARC A/C = AIR CONDITIONER PAD AE. = ANCHOR EASEMENT NR = ALUMINIUM ROOF NS = ALUMINIUM SHED ASPH. =ASPHALT B.C. = BLOCK CORNER B.C.R. = BROWARD COUNTY RECORDS B.M. = BENCH MARK B.O.B. =BASIS OF BEARINGS C = CALCULATED C.B. = CATCH BASIN C.B.W. = CONCRETE BLOCK WALL CH = CHORD CH.B. = CHORD BEARING CL = CLEAR C.LF. = CHAIN LINK FENCE C.M.E. = CANAL MAINTENANCE EASEMENTS CONC. = CONCRETE C.P. = CONCRETE PORCH C.S. = CONCRETE SLAB D.E. = DRAINAGE EASEMENT D.M.E. = DRAINAGE MAINTENANCE EASEMENTS DRIVE = DRIVEWAY ENCR. = ENCROACHMENT E.T.P. = ELECTRIC TRANSFORMER PAD F.F.E. = FINISHED FLOOR ELEVATION F.H. = FIRE HYDRANT F.I.P. = FOUND IRON PIPE F.I.R. = FOUND IRON ROD F.N. = FOUND NAIL F.N.D. = FOUND NAIL & DISK FNIP. = IN.&EG. = LF.E. _ LM.E. LP. _ M.= M/H = NAP. _ NGVD = N.T.S. = O.H.L O.R.B. 0/S = OVH. _ P.B. _ P.C. = P.C.C. = PL = P.LS. _ FEDERAL NATIONAL INSURANCE PROGRAM INGRESS AND EGRESS EASEMENT LOWEST FLOOR ELEVATION LAKE MAINTENANCE EASEMENT LIGHT POLE MEASURED DISTANCE MANHOLE NOT A PART OF NATIONAL GEODETIC VERTICAL DATUM NOT TO SCALE OVERHEAD UTILITY LINES OFFICIAL RECORD BOOK OFFSET OVERHANG PLAT BOOK POINT OF CURVE POINT OF COMPOUND CURVE PLANTER PROFESSIONAL LAND SURVEYOR P.O.B.. = POINT OF BEGINNING P.O.C.. = POINT OF COMMENCEMENT P.P. = POWER POLE P.P.S.. = POOL PUMP SLAB P.R.C. = POINT OF REVERSE CURVE PRM = PERMANENT REFERENCE MONUMENT PT. = POINT OF TANGENCY PVMT. = PAVEMENT PWY = PARKWAY R. = RECORD DISTANCE RAD. = RADIUS OF RADIAL RGE. = RANGE R.P. = RADIUS POINT R.O.E. = ROOF OVERHANG EASEMENT R/W = RIGHT -OF -WAY SEC. = SECTION S.I.P. = SET IRON PIPE L.B. #6044 SWK. = SIDEWALK T = TANGENT TWP = TOWNSHIP U.E. = UTILITY EASEMENT U.P. = UTILITY POLE W.M. =WATER METER W.R. = WOOD ROOF W.S. = WOOD SHED = ANGLE . = CENTRAL ANGLE = CENTER LINE = MONUMENT LINE LEGAL NOTES TO ACCOMPANY SKETCH OF SURVEY PSURVEY"), - THERE MAY BE EASEMENTS RECORDED IN THE PUBLIC RECORDS NOT SHOWN ON THIS SURVEY. - THE PURPOSE OF THIS SURVEY IS FOR USE IN OBTAINING TITLE INSURANCE AND FINANCING, AND SHOULD NOT BE USED FOR CONSTRUCTION PURPOSES. - EXAMINATIONS OF THE ABSTRACT OF TITLE WILL HAVE TO BE MADE TO DETERMINE RECORDED INSTRUMENTS, IF ANY, AFFECTING THE PROPERTY. THIS SURVEY IS SUBJECT TO DEDICATIONS, LIMITATIONS, RESTRICTIONS, RESERVATIONS OR EASEMENTS OF RECORD, AND LEGAL DESCRIPTIONS PROVIDED BY CLIENT OR ATTESTING TITLE COMPANY. BOUNDARY SURVEY MEANS A DRAWING AND / OR A GRAPHIC REPRESENTATION OF THE SURVEY WORK PERFORMED IN - THE FIELD, COULD BE DRAWN AT A SHOWN SCALE AND / OR NOT TO SCALE. EASEMENTS AS SHOWN ARE PER PLAT BOOK, UNLESS OTHERWISE SHOWN. - THE TERM "ENCROACHMENT' MEANS VISIBLE AND ABOVE GROUND ENCROACHMENTS. - ARCHITECTS SHALL VERIFY ZONING REGULATIONS, RESTRICTIONS AND SETBACKS, AND THEY WILL BE RESPONSIBLE - FOR SUBMITTING PLOT PLANS WITH THE CORRECT INFORMATION FOR THEIR APPROVAL FOR AUTHORIZATION TO AUTHORITIES IN NEW CONSTRUCTIONS, UNLESS OTHERWISE NOTED. THIS FIRM HAS NOT ATTEMPTED TO LOCATE FOOTING AND /OR FOUNDATIONS. FENCE OWNERSHIP NOT DETERMINED. - THIS PLAN OF SURVEY HAS BEEN PREPARED FOR THE EXCLUSIVE USE OF THE ENTITIES NAMED. • HEREON, THE CERTIFICATE DOES NOT EXTEND TO ANY UNNAMED PARTY. - THE SURVEYOR MAKES NO GUARANTEES AS TO THE ACCURACY OF THE INFORMATION BELOW. THE LOCAL F.E.M.A. - AGENT SHOULD BE CONTACTED FOR VERIFICATION. THE FNIP FLOOD MAPS HAVE DESIGNATED THE HEREIN DESCRIBED LAND TO BE SITUATED IN ZONE: X COMMUNITY/PANEL/SUFFIX 120882 0308 L DATE OF FIRM: 08/11/2009 BASE FLOOD ELEVATION: NIA. CERTIFIED TO: RAQUEL WOOLIN h LEGEND TYPICAL —0H- OVERHEAD UTILITY LINES 2a=2 CBS = WALL ICBM -14-1F C.L.F. = CHAIN LINK FENCE -0-0- I.F. = IRON FENCE - 44--4r W.F. = WOOD FENCE ■ 0.00 = EXISTING ELEVATIONS • SURVEYOR'S NOTES 1) IF SHOWN, BEARINGS ARE REFERRED TO AN ASSUMED MERIDIAN, BY SAID PLAT IN THE DESCRIPTION OF THE PROPERTY. IF NOT, THEN BEARINGS ARE REFERRED TO COUNTY, TOWNSHIP MAPS. 2) THIS IS A SPECIFIC PURPOSE SURVEY. 3) THE CLOSURE IN THE BOUNDARY SURVEY IS ABOVE 1:7500 FT. 4) IF SHOWN, ELEVATIONS ARE REFERRED TO MIAMI -DADE COUNTY. ALL ELEVATIONS SHOWN ARE REFERRED TO NATIONAL GEODETIC VERTICAL DATUM OF 1929 MIAMI DADE COUNTY BENCH MARK NO. N -603 -R LOCATOR NO. 3250 SW ELEVATION 8.11 FEET OF N.G.V.D. OF 1929 SURVEYOR'S CERTIFICATION I HEREBY CERTIFY: THAT THIS "BOUNDARY SURVEY" OF THE PROPERTY DESCRIBED HEREON, AS RECENTLY SURVEYED AND DRAWN UNDER MY SUPERVISION, COMPLIES WITH THE MINIMUM TECHNICAL STANDARDS AS SET FORTH BY THE FLORIDA BOARD OF PROFESSIONAL LAND SURVEYORS IN CHAPTER 61 G77-8, FLORIDA ADMINISTRATIVE CODE PURSUANT TO 472.027, FLORIDA STATUTES. c BY: // FI LD W T OF F 1N ROBERT !BARRA ([SAORK) PROFESSIONAL LAND SURVEYOR NO. 6437 STATE OF FLORIDA (VALID COPIES OF THIS SURVEY WILL BEAR THE EMBOSSED SEAL OF THE ATTESTING LAND SURVEYOR). REVISED ON: REVISED ON: SURVEYOR'S SEAL S Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 162298 Scheduled Inspection Date: September 08, 2011 Inspector: Bruhn, Norman Owner: WOOLIN, RACHEL Job Address: 489 NE 95 Street Miami Shores, FL 33138- Project: <NONE> Contractor: MARS POOLS Permit Number: BPP -7 -11 -1316 Permit Type: Pools/Whirlpools /Hot Tubs Inspection Type: Final Work Classification: New Phone Number Parcel Number 1132060140640 Phone: (954)214 -2844 Building Department Comments NEW INGROUND POOL AND TUMBLED MARBLE PAVER DECK Passed Failed Inspector Comments Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. September 07, 2011 For Inspections please call: (305)762 -4949 Page 15 of 47 PERMIT # 1 V '\ -°-41 '''1 CO C CONTRACTOR: I X , 2 Po-01-5S SUBMITTAL DATEQZA 90101011 ADDRESS:4 Nit gs5i- NAME: f X \i ,J RESUBMITAL DATES: PROJECT TYPE: 51),) 1 t NG) ''D\ AKp -121111 ZONING FIRE i (PV.- Y / , 1/104 tl IMPACT FEES STRUCTURAL / ELECTRICAL HRS/DERM PLUMBIN NOC 0 \ 'A '`a, MECHANICAL BLDG c1.9411-- 666- 7.0 Bet 1NG PERMIT APPLICATION FBC 20 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit No. f5??... 11 -‘31u Master Permit No. Permit Type: BUILDING ROOFING OWNER: Name (Fee Simple Titleholder : l�24)UP / 1t,2OI'll Phone #: 7•36-g%9,�'t� %V Address: 1(89 /76 VS' 5/ City: (.4/ /a c5` tt's State: �� Tenant/Lessee Name: Phone #: Email: Zip: 33/3E JOB ADDRESS: 9U 9 ,c4; 9S f (57`. City: Miami Shores County: Folio/Parcel #: ^ 3(270 0 Miami Dade Zip: 33/38 Is the Building Historically Designated: Yes NO i ' Flood Zone: CONTRACTOR: Company Name: ��r [ 415 /D % 71C. Phone #: tad-Z/(- ?SW Address: £q 1 it/!k) /02 4 U6 it 236- City: Sti 7 r ! /�S% P State: fLJ Zippy: .? 3 3 �' / Qualifier Name: Mtn e //s71,0,4)1r1 Phone #: Q�`7' 2/v-Z 'q' State Certification /orbRegistration #: (2 PC /7 57922 Certificate of Competency #: Contact Phone #: Q 5 $ / 2 / y 2 8419? Email Address: /t$/2()€) / 4.7 t O /• C 494 / DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ ZS 0(20 • (9( Square/Linear Footage of Work: U 7 Type of Work: ❑Addition ❑Alteration J ;0 -w ❑^Reeppair/Replace �% °Demolition Desc ' tion of Wor : /V oo �Yf cot) 14 L oo / `�` A4- th /e(T / #'Z 4 ` /e aver toe ***** :+ x**: x* ****** a: **: x**** *+x************Fees* * *** x** **** ** *+x******* ** ** *** ********** Submittal Fee $ SO , 00 Permit Fee $ C7 SV PAtb Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Ws' CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ $ qt-IAM 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, BOIT FRS, 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 "" Signature Owner or Agent Contractor The foregoinj instrument was ac ledged be for me thi The fore . +, ,} instrument is acknowl e' fore �e day of Tay , 20 )/ , by 4. Q t)Q 10 day of J , 201 f , b who is personally known to me or who has produced /—(-- who is personall known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: .A ***** *** * *sksksk»s******** Z,pY P4 r >� GWENDOLYN B. STEWART MY COMMISSION 4 DD961586 q 0. EXPIRES: April 19, 2014 1401 -3- NOTARY F7. NOti y Disco,j , Assoc. Co. �pak>ksNk�k.. APPROVED BY ' >1f iAl3"' 7/ 'y L /{ (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) as identification and who did take NOTAa PUBLIC. Sign: Print: My Commission Ex u : b ps'• ********************************U********* $ ************** Plans Examiner Qo 2,, 7/ Zoning Structural Review Clerk Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 REQUIREMENTS FOR POOL PERMIT ** *PRIME CONSTRACTOR AND ALL SUBCONTRACTOR PERMITS MUST BE SUBMITTED PRIOR TO PERMIT APPROVAL * ** Building p rmit application must be accompanied by: Sub permit applications (Electrical, Plumbing, Mechanical) IL/2 Copies of survey (no more than 7 years). ❑ If survey is older than 7 years it needs Survey Affidavit. 2 Sets of plans signed and sealed. Show on the plans: Location of septic system, all intended setbacks of pool, location of the pool equipment, deck and fences. Plans shall be reviewed and approved by HRS department. Residential swimming pool, spa and hot tub Safety Act form completed and si ned by owner. ' ming pool Owner's Certification form completed and signed. Restrictive Covenant Protective Pool Enclosure form completed and NOTE: d by owner. f manufacturer specifications for safety net, barrier or alarm. roof of ownership. 1. Application fee of $250.00 due at the time of submittal for Building permit, and $50.00 for each sub permit. Miami Shores Viitage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 SWIMMING POOL OWNER'S CERTIFICATION Date -7 . 1 • Miami Shores Village Building & Zoning Department Attention: Building Official certify that I am the legal owner of the property described as Sec 2P /0-3 7/0 4 c734 49/1< 53 , located at ta 9/167 95 In accordance with Section 33- 12(f), Code of Metropolitan Dade County, I certify that I understand and agree that the swimming pool to be constructed at the above address cannot be used or filled with water until separate permit has been obtained for an approved safety barrier, and such barrier erected, inspected and approved. further understand that this certification, however, does not eliminate the need for obtaining a permit and erecting and approved barrier prior to final inspection and use of the pool. Legal Owner Note: This certification is to be submitted with a swimming pool permit applica Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 RESTRICTIVE COVENANT PROTECTIVE POOL ENCLOSURE KNOW ALL MEN BY THESE PRES: WHEREAS, the undersigned Ka-quell Woolf)1 i s /are the fee simple owner(s) of the following ib d& "d following described property s ted and being in Miami hores VII Florida Address: L0 % , S- 4 S7 /M1/41. o 57 'f(.S 33 /Y Whereas, the undersigned owner(s) Q 1✓e desire to utilize said Lot(s) as a single building site, and the undersigned owners) do(es) hereby declare and agree as follows: That the property will not be used in violation of any ordinances of Miami Shores Village or Miami -Dade County now in effect or hereinafter enacted. II. That the purpose of the covenant is to induce Miami Shores Village to issue a permit for a pool where the required enclosure is not on the subject property where the pool is located. III. That if any of our adjoining neighbors remove any portion of their fence or wall, or if our /my property shall fail to meet code requirements for pool barriers, we, as owners will immediately install a protective enclosure to meet code requirements and will obtain a permit for such fence. IV. That, /Ave, as owner(s) hold Miami Shores Village harmless for any negligence or injury that results from not having the enclosure. V. If enclosure belongs to said property, I agree to maintain & or replace said enclosure in the event that is damaged or removed by any case. NOW, THEREOF, for good and valuable consideration, the undersigned do(es) hereby declare that he /she will not convey or cause to be conveyed the title to the above property without requiring the successor in title to abide by all terms and conditions set forth herein. FURTHER, the undersigned declare(s) that this covenant is intended and shall constitute a restrictive covenant conceming the use, enjoyment and title to the above property and shall constitute a covenant running with the land and shall be binding upon the undersigned, his/her successors and assigns and may only be released by Miami Shores Village, or its successors, in a - �- of said Village then in effect. • OWNER SI‘c N & PRINT OWNER SING & PRINT Aa Cis 4tL W OWL. /..t) I Here Certify at on this day personally appeared before me A �'�� / " `' and has produced ID # fri- ,� /® as identification and he/she acknowledge that he/she executed the foregoing, freely and voluntarily, for purposes ere in expressed. d / > SWORN TO AND SUBSCRIBED before me on this 24 u� day of r% 20 / r TARY PUBLIC ST ' OF FLORI (Revised 05/2209 '`'`% GWENDOLYN , m °� MY COMMISSION # DEWART "Fee EXPIRES: 2014 � 1400- NOTARY 19.2414 F1' Noisy Disca°m Aaw,o Co. Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 NOTICE OF REQUIREMENTS RESIDENTIAL SWIMMING POOL, SPA AND HOT TUB SAFETY ACT I (We) acknowledge that a new swimming pool, spa or hot tub will be constructed or installed at Miami Shores, FL, and hereby affirm that one of the following methods will be used to meet the requirements of Chapter 515, Florida Statues and the Florida Building Code R4101.17. Please initial the method(s) to be used: 1 i -' The pool will be equipped with an approved safety pool cover that comp lies with ASTM F1346 -91. (Submit Manufacturer's Specifications). A continuous, one -piece (child) barrier meeting the requirements of Florida Building Code R4101.17.1.15 will protect the pool perimeter. The plans shall show the fence location and method of attachment, including one end that shall not be removable without the aid of tools. (Submit Manufacturer's Specifications), A combination of non - dwelling walls and fences (screen enclosure, child fence, masonry fence walls, chain link or wood fence, etc.) will protect t he pool perimeter. The plans must specify t he type and location of all non dwelling walls. Florida Building Code, R4101.17.1 Any combination of protection which incorporates dwelling walls with openings directly into the pool perimeter and all windows and doors will be equipped with exit alarms complying with Florida Building Code, R4101.17.1.9 (Submit Manufacturer's Specifications). Any combination of protection which incorporates dwelling walls with openings directly into the pool perimeter and all doors will be equipped with a self - latching device with positive mechanical latching/locking installed a min. 54" above the threshold. If this option is selected, submit plans showing all types and location of all perimeter protection. The plans must also show the location and type of all openings, and the hardware type for each location. (Submit Manufacturer's Specifications). In accordance with the Code, the pool may not be filled with water without compliance with the Private Swimming Pool Safety Requirements, and upon expiration of the permit, the pool shall be presumed to be unsafe . I understand that not having one of the above installed will constitute a violation of Chapter 515, F.S ., an d will be considered as committing a misdemeanor of the second degree, punishable s . r ided in S ion 775.082 or Section 775.083 F.S . This form must be signed b wne,agepf° t e �` me ntractor. /!C�la,(� `7 -2 &v/ . CO �TRRACT R'S SI ATURE D DATE 0 R'S SIGNATURE AND DATE /�'!, �/ / / / /Ake fin/ t/9, ✓ /%)i"i � � CONTRACTOR'S NA E (PLEASE PRINT) NOTARY PUBLIC OWN NO ARY GIV2N6GLYN E. ST EVA MV COMMISSION N D99E15mb acx n " EXPIRES: April 19, 2014 I- MOTNiY a Notary Dimwit Arso¢. Co. TAM 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954- 831 -4000 VALID OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011 DBA: Receipt #:188- 238920 Business Name: MARS POOLS INC Business Type:PO MARINE CONTRACTOR Business Opened:o2 /02/2011 # 235 State /County /CertlReg:CPPC1457922 Exemption Code: Owner Name: MICHAEL STEWART Business Location: 5405 NW 102AVE SUNRISE Business Phone: Rooms Seats Employees 1 Machines Professionals THIS RECEIPT MUST BE THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: MARS POOLS INC 511 SE 5 AVE FORT LAUDERDALE, FL POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS This tax is levied for the privilege of doing business within Broward County and is non - regulatory in nature. You must meet all County and/or Municipality planning and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. 33301 2010 - 2011 Receipt #108 -10- 00001345 Paid 02/02/2011 27.00 For Vending Business umy Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: MARS POOLS INC 511 SE 5 AVE FORT LAUDERDALE, FL POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS This tax is levied for the privilege of doing business within Broward County and is non - regulatory in nature. You must meet all County and/or Municipality planning and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. 33301 2010 - 2011 Receipt #108 -10- 00001345 Paid 02/02/2011 27.00 06 -23 -2010 ALEX SINK STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TD BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: PERSON: FEIN: BUSINESS NAME MARS POOLS INC 1908 SW 84 TERR NO LAUDERDALE 08/07/2010 EXPIRATION DATE: 08/06/2012 STEWART MICHAEL 412038381 AND ADDRESS: FL 33068 SCOPES OF BUSINESS OR TRADE: 1- POOL CONSTRUCTION 3- POOL DECKS 2- CERTIFIED POOL CONTRACTOR 4- POOL PIPING IMPORTANT: Pursuant to Chapter 440 . 05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DMSION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 08/07/2010 EXPIRATION DATE: 08/08/2012 PERSON: MICHAEL STEWART FEIN: 412038381 BUSINESS NAME AND ADDRESS: MARS POOLS INC 1908 SW 84 TERR NO LAUDERDALE, FL 33068 SCOPE OF BUSINESS OR TRADE 1- POOL CONSTRUCTION 2- CERTIFIED POOL CONTRACTOR 3- POOL DECKS 4- POOL PIPING IMPORTANT Pursuant to Chapter 440.05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. MC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 DEPARTMENT OF -'4UWSS AND PROFESSIONAL REaTTL WON CONS TRUCTION4'D RY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 STEWART, MICHAEL RAYNARD MARS POOLS INC 1908 SW 84TH TER NORTH LAUDERDALE FL 33068 (850) 487 -1395 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and leam more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE IS. CEitA, D un4$r �lxe provisions p9p3?carniott ices ;AU�s 314. L1064:'409.8...4 •. R CERTIFIdlikE OF LIABILITY INSURA E OPID CDL DATE O o' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Lanza Insurance Agency Inc. 9900 W Sample Road - Ste 300 Coral rin s FL 33065 g Phone:954- 825 -0424 Fax:954- 825 -0425 LAM IAk. I NAME: PHONE FAX Ext): (A/C, No): are, Lo, ADDRESS: PRODUCER CUSTOMER ID #: MARSP -1 INSURER(S) AFFORDING COVERAGE NAIC# INSURED Mars Pool Inc. 5405 NW 102 Avenue #235 Sunrise FL 33351 INSURERA: Catlin Specialty Ins Co INSURERB: 0900100969 INSURERC: 07/24/11 INSURER D : $ 500,000 INSURER E : PREMSES(Ea�occurrence) INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE NSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSR W SVD POLICY NUMBER /YYYY) (MMM/DDDY (MMIDDIYYYY) LIMITS A GENERALUABILITY COMMERCIAL GENERAL LIABIUTY OCCUR 0900100969 07/24/10 07/24/11 EACH OCCURRENCE $ 500,000 X PREMSES(Ea�occurrence) $ 100,000 CLAIMS -MADE X MED EXP (My one person) $ 5,000 PERSONAL &ADVINJURY $ 500,000 GENERAL AGGREGATE $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $ 500,000 X POUCY JECT LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE OMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE1 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N I A WC STATU- OTH- TORY UMITS ER E.L. EACH ACCIDENT $ f l E.L. DISEASE - EA EMPLOYEE $ below E.L DISEASE - POLICY UMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101 Additional Remarks Schedule, If more space Is required) SWIMMING POOL CONTRACTOR - Faxed 954 -475 -8983 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Fax: 305 - 756 -8972 10050 NE 2 Ave M iami Shores FL 33138 MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATIVE ;;];;N4klbSk . ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 11 Ice Inspection Number: INSP - 162305 Scheduled Inspection Date: August 31, 2011 Inspector: Devaney, Michael Owner: WOOLIN, RACHEL Permit Number: EL -7 -11 -1318 Job Address: 489 NE 95 Street Miami Shores, FL 33138- Project: <NONE> Contractor: JACQUES ELECTRIC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Pool - Private Phone Number Parcel Number 1132060140640 Phone: (954)214 -8711 Building Department Comments HOOKUP POOL EQUIPMENT ONLY Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments /,,c(C-1/ August 30, 2011 For Inspections please call: (305)762 -4949 Page 17 of 34 rho T,111 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): %q /16 `44'i,' she/e$ Address: City: Tenant/Lessee Name: Permit No. L - i 1- t3 l8 Master Permit No. gpp- 151ko State: Phone #: l 16 8! %c70/ V Zip: 3 3 l3 E Phone #: Email: JOB ADDRESS: (a g 741 571a City: Miami Shores County: Folio/Parcel #: l! ' 3c2t 6 •l9' Miami Dade Zip: 33/ ?37 Is the Building Historically Designated: Yes NO Flood Zone: iQOQues Phon '' // (� C PG � Phone: �� � �l y' CONTRACTOR: CompanxName: Address: 5;0 ' rr City: Qualifier Name: State: ohm 6220 'V o G Go%� State Certification or Registration #: 0l 0 9 p 7 Z Contact Phone #: 9$ Email Address: ,`4; l/ Zip: 33027 7 Phone #: CV- 2, y^7// Certificate of Competency #: e6200/7.23R c!c /9 deo 4eilicorn DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ /2 006,00 Sgquuare/Linear Footage of Work: Type of Work: ❑Address UAlteration UJiVew ❑R air/Replace ❑Demolition Description of Work: /.I4 D /Li),2 /`v� / ( �� j ei / �i lc. Submittal Fee $ So, Dfl Permit Fee $ 7" "e2'1'•° CCF $ CO /CC $ P,k c> Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ g(1) "v-Q 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 cr..-c2.46z. . Owner or Agent The foregoing instrument was ac ledged b ore me this day of 14l , 20 1 1, by k i?�e A1°0 ,'o who is personally known to me or/who has produced FL As identification and who did take an oath. NOTARY PUBLIC: Sign: Print. My Commission Expires: GW WENDOLyiV B. STEWART MYCU � M��SSION # DD961586 1.800-3, igt*****814tiLoital EXPIRES: &o, fix. Co. APPROVED BY Aor Pr The foregoing instrument was acknowledged before me this day of -SO/7 ,20 ii, by 50h l 44. Lei Ol% who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: P My Commission Exp. * * * * * * * * * * * * * * * ** * * * * * * * * * ** ‘,.4"-;)WAY Illans Examiner Structural Review (Revised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09) n y cu©OLYNB. STEWART ' "vsslorrann961s86 ' ?-xorAR? 1 ' APri119. 2014 ** Zoning Clerk cc__ CERTIFICATE OF LIABILITY INSURANCE DATE T(/17D111 PRODUCER Accredited Insurance 6 6099 Hollywood Blvd Hollywood, FL 33024 Phone (954)964 -5444 Fax (954)964 -0772 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED JOHN M. LADOW JACQUES ELECTRIC, INC 7450 FARRAGUT STREET !HOLLYWOOD, FL 33024 INSURER A: NATIONAL GROUP INSURANCE INSURERS* INSURER C: INSURER 0: INSURER E: COVERAGES INSURER F: THE POUCIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADM. INSRD TYPE OF INSURANCE POLICY NUMBER 07B0000002800 POLICY EFFECTIVE DATE (MMIDDIYY) 05/18/11 POUCY EXPIRATION DATE (MMIDD/YY) 05/18/12 LIMITS EACH OCCURRENCE 1,000,000 A • GENERAL M • ■ ❑ GEM. l"rI COMMERCIAL • LABILITY GENERAL LIABIUTY CLAIMS MADE ' OCCUR PPR MISES ce) 100,E MED EXP (Any one person) 5,000 PERSONAL & ADV INJURY 1,000,000_ GENERAL AGGREGATE 2,000,000 AGGREGATE LIMIT APPLIES PER POLICY ❑ PROJECT • LOC PRODUCTS - COMP /OP AGG 2,000,000 AUTOMOBILE • ❑ • • ❑ • • • LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY ❑ • ANY AUTO • AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY ❑ OCCUR • CLAIMS MADE • ❑ DEDUCTIBLE ❑ RETENTION $ EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? I yes under SPECIAL PROVISIONS below • ORY Cy� ANIR ER - L(S EL EACH ACCIDENT E L DISEASE - EA EMPLOYEE EL DISEASE - POUCY UMIT OTHER DESCRIPTION OF OPERATION 1 LOCATIONS / VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ELECTRICAL WORK CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED `' ATE k ACORD 25 (2001108) QF ACORD CORPORATION 1988 ACQRD CERTIFICATE OF LIABILITY INSURANCE I DATE(MWDDIYYYY) 3/31/2011 PRODUCER IMPACT INSURANCE SERVICES LLC 18064 SW 33 Court Miramar, FL 33029 0354) 8851884 INSURED THIS CERTIFICATE IS SAS A MATTER OF INFORMATION ONLY AND CONFERS PIO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW INSURERS AFFORDING COVERAGE NAIC Tf JACQUE1S ELECTRIC INC. 7450 FARRAGUT STREET HOLLYWOOD, FL 33024 09S/11714-R711 eaeirk COVERAGES IAA: FL CITRUS, BUSINESS & IND. FUN 31259 INSURER E: INSURER a INSURER 0: INSURER E THE POUCIES OF UMURANCE UBTEDBELOWHAVE BEEN ISSUED TO THE INSURED NAMED ABOVEFOR THE POLICY PERIOD INDICATED. IOIVBTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH REACT TO WHICH THIS CBtTIFICATE MAY BE ISSUED OR NAY PERTAIN, THEINSURANCE AFFORDED BY THE POUCTESCESCRIBED THE POUCIESQHEREIN IS swam TOAU.THE TERMS. AND COMMONS OF SUCH POLICIES. ABATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAIDC AB✓ S. tilta 100'1 LTR IAISIO TYPE OF INMURANCE POLICY NUMBER MEOW DA E7 MOTS GENERAL LIABILITY COMMERCIAL GCRAL LIABILITY IC.LAB BRIDE n OCCUR GENT. ANTE LIMIT APPLIESPEM POICY f owc AUTOMOBILE UANLTY ANYAUTO ALLOWED AUTOS SCHEDULED AUTOS MOD AUTOS 1 -OI N ED AUTOS EACH OCCURRETCE 3 �/liMRCiL' It? IitP1It PREMSES (Ea oolrenaaj IINED MCP (Ann I PERSONAL BADVINJUiY GENERAL ANTE DUCTS -t OP AGG LE UNIT (Es $ BODILY INJURY "sr parson) $ BODILY INJURY (Pere PROPERTY DAMAGE (Perwdde d) $ GARAGE UABt1RY ANYAUTO AUTO ONLY- EAACCIDEDf i OTHER THAN A TOTOOM.Y-. EAACO AGG a • A MICESSIUMBRELIA UABILRY —I n 01 NDMADE EACH OCCURRMME a ANTE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY oFficERAIEMBER SCUM? Ayes dean betmder SPECIAL PROVISIONS Wow 10637108 4/1/2011 4/1/2012 x 11161y ulTIA I IER EL EACH ACCIDENT EL DISEASE- EABIPLOYEE EL DID- POLICY LEST OTHER • 100,000 • 100,000 8 500, ©00 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHII.T /EXCLUSIONS ADIMO BY /SPECIAL CERTIFICATE HOLDER CANCELLATION A CORDE5 (2BUW) MIAMI SHORES VILLAGE BUILDING DEPT. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 1 SHOULD ANY OFTHE ABOVE D BED POUCIEB BE CANTED THE EXPIRATION DATE THEE. THE MUMS mtsuast Mal EM£AV R TO MAIL. 30 DAYS WRITTEN NOTICE TO THECERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TOW SO SHALL IMPOSE NO °ROGATION OR LLIABUI1Y OF ANY KIND UPON THE IPA, ITS AGENTS OR d/fFiORIaD REPRESENTATMES. DACORD CORPORATION1988 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 CC2 Inspection Number: INSP- 162299 Permit Number: PL -7 -11 -1317 Scheduled Inspection Date: August 31, 2011 Inspector: Hernandez, Rafael Owner: WOOLIN, RACHEL Job Address: 489 NE 95 Street Miami Shores, FL 33138- Project: <NONE> Contractor: MARS POOLS Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Pool - Private Phone Number Parcel Number 1132060140640 Phone: (954)214 -2844 Building Department Comments POOL MAIN DRAIN, POOL PIPING Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments August 30, 2011 For Inspections please call: (305)762 -4949 Page 14 of 34 q_ Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING 7 OWNER: Name (Fee Simple Titleholder): (/ a 1J' v[/ �� // Phone#: 7g6-2379:46 7 Address: ♦/9 /(.1(; ,9s 17 is ` ,--- City: 1/ ,'o !1i J� / D/�P.5 State: re--- Zip: 3 138 Tenant/Lessee Name: Phone #: Email: Permit No. pt- 11 - 13 11 Master Permit No. (3 P P- ►\ -131 to JOB ADDRESS: / ( /16 9S- " 5/ City: Folio/Parcel #: Miami Shores Coun : Miami Dade Zip: 3 3 13 g /- 3226 — Q /y-- O Is the Building Historically Designated: Yes NO v Flood Zone: CONTRACTOR: Company Name: �!/ /t f1 /4D % //2( Address: 5-lac /tl42 /0 2 /9(/6 0.73,' City: �v / ?L. te: -4- Qualifier Name: /Ci , Sr 1- a Phone #: Zip: 3 373 c-1 Phone #: 9S9- 2(ci State Certification or Registration #: CPC / 2' 7 % ZZ Certificate of Competency #: 9 % 7 2 / / 2 lit/c/ Email Address: Q('S/)9e /50 D!/ •COCk% DESIGNER: Architect/Engineer: Contact Phone #: Phone #: Value of Work for this Permit: $ 2/D001 v Square/Linear Footage of Work: Type of Work: Address ❑Alteration LiNew Repair Lace ❑Demolition Description of Work: n1 ca' `� Q -7 5 •x,��xu.** �x�x�x�x�x�x�x�xx�x��x**** �x�xx�***** * ** **Fees* ****** ******** * **** ** * **** ***� ****x��x�x*** Submittal Fee $ 50.0 0 Permit Fee $ _ ***.*Fees* $ CO /CC $ PALO Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 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 absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature LC cc Owner or Agent The foregoing instrument was ackn wledged before me this A ; I. 20 f1,by g47v9/ Wit iP) day of who is >ersonally known to me or who has produced / L- The fore day of who is perso Contractor strument was acknowl ,20 I1, by who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: / a Sign: /� s���' `i . r // Sign: Print: , Print: My Commission Expire % GV ENDOLYN B. STEAWART My Commission Expires: r01.V",). , =5 cyt,�' G�o �a ° MY EXPIRES: COMMISSION k D2014 6 ��1c 1'G p� s' EXPIRES: A1p�ril 19, 2014 ^-9,131 T •3- NOTARY 11. No Viscoya[AR°45 �'p, �0 **********************k *** * n "s **skak*H« tkds ak*tk**de*tk****i ksk**** ***sk****= H****skds***8 +*=k*****+k**ok**** APPROVED BY Z s -i/ Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06/10 /2009)(Revised 3/15/09) 111111111111111111111111111111111111111111111 CF N 201 1 804763 1 OR &k 27761 Fss 1522 - 1523; (lass) RECORDED 07/19/2011 14017 :23 HARVEY RUVI41r..CLERK OF COURT MIAIII -DADE COUNTY, FLORIDA NOTICE OF COMMENCEMENT A RECORDED-COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO. TAX FOLIO NO. /IL 3X O/V —V4 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. 1. Legal description o property ' d stre / - • • res Pi ,- MAIM 2. Description of improvement: Swr Owner(s) name and address: Interest" t b property: n }: Name and a ddre o ple�t+ttetser` 4. Contractor's name and addressy /45s Aftw/ 57c ,.. £4't4 373s-/ urety: (Payment $ond r equired bpi o t-hrn contractor, if any) Name .and Address: Amount of bond $ ' 6. Lender's name and address: 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. OR Bk 277'61 PG 1523 LAST PAGE 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: a Expiration date of this Notice of Commencement (the expiration date is .1 year, from.,. the date of recording unless a different date is specified) Print by. Prepared Sworn to and- subscribed before me this day of 'Jv ! 20 / Notary Public: Print.N 'My commission expires: al/ At° t? 333$/ 5582 N.W. 7th STREET SUITE 202 MIAMI4FLeRial 33126 TELEPHONE: (305) 220 -3171 FAX: (305) 264-0229 DRAWN BY: TULY /ARY Hint urtrru irs LAND SURVEYORS 405U1JVEY No. 05- 7557 -3 SHEET No. 2 OF 2 BOUNDARY SURVEY SCALE = 1" : 20' SURVEY ENCROACHMENT NOTES: A)NORTH SIDE OF PROPERTY UTILITY POLE AND OVERHEAD UTILITY LINE ENCROACHING ONTO SUBJECT PROPERTY. F.I.P 1/2" NO CAP 0.50' CL. 0.90' CL. F.I.P 1/2" NO CAP o U.P. 15'ALLEY (N.A.P.) 27,58' LOT - 23 BLOCK -53 IIII TILE CONC. DRIVE N CO 13.60 CO 17.90' ONE STORY RES. #489 F.F.E: 11.63' I GARAGE ELEV. =9.17' 27.02 16.85' 90 °23'05" r 4.15' N F.I.P 1/12" NO CA' 30.00' 60 00' TOT R/W 62.95 LOT -24 BLOCK - 53 PL c.s. W.M. 34.43' 9 15.15' 17.60' N STEP 5' CONC. SWK 104 36' 25' PWY PL. in 30.00' B.C. F.I.P 1/2" NO CAP 20' ASPHALT. PVMT. N.E. 95th STREET SURVEYOR'S NOTE: - There may be Easements recorded in the Public Records not shown on this Survey. R= 25.00' L= 39.49' T= 25.22' L1 =90 °30'20" CH= 35.51' uJ W led 6582 N.W. 7TH STREET, SUITE 202 MIAM3, FL 33126. TELEPHONE: (305) 264-2660 FAX: (305) 264-0229 DRAWN BY: AS Nova Surveyors, Inc. LAND SURVEYORS SURVEY NO 5- 0007557 -4 SHEET NO 1 OF 2 SURVEY OF LOT 23 -24, BLOCK 53, OF MIAMI SHORE SECTION NO. 2, ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK 10, PAGE 37, OF THE PUBLIC RECORDS OF MIAMI -DADE COUNTY, FLORIDA. PROPERTY ADDRESS: 489 NE 95 ST, MIAMI SHORES, FL 33138 FOR: RAQUEL WOOLIN LOCATION SKETCH Scale 1" = NT.S. S -H - R :? T.,. 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I�o ABBREVIATION AND MEANING A =ARC NC = AIR CONDITIONER PAD A.E. = ANCHOR EASEMENT NR = ALUMINIUM ROOF NS = ALUMINIUM SHED ASPH. = ASPHALT B.C. = BLOCK CORNER B.C.R. = BROWARD COUNTY RECORDS B.M. = BENCH MARK B.O.B. = BASIS OF BEARINGS C = CALCULATED C.B. = CATCH BASIN C.B.W. = CONCRETE BLOCK WALL CH = CHORD CH.B. = CHORD BEARING CL = CLEAR C.L.F. = CHAIN LINK FENCE C.M.E. = CANAL MAINTENANCE EASEMENTS CONC. = CONCRETE C.P. = CONCRETE PORCH C.S. = CONCRETE SLAB D.E. = DRAINAGE EASEMENT D.M.E. = DRAINAGE MAINTENANCE EASEMENTS DRIVE = DRIVEWAY ENCR. = ENCROACHMENT E.T.P. = ELECTRIC TRANSFORMER PAD F.F.E. = FINISHED FLOOR ELEVATION F.H. = FIRE HYDRANT F.I.P. = FOUND IRON PIPE F.I.R. = FOUND IRON ROD F.N. = FOUND NAIL F.N.D. = FOUND NAIL & DISK FNIP. = FEDERAL NATIONAL INSURANCE PROGRAM IN. &EG. = INGRESS AND EGRESS EASEMENT L.F.E. = LOWEST FLOOR ELEVATION L.M.E. = LAKE MAINTENANCE EASEMENT L.P. = LIGHT POLE M. = MEASURED DISTANCE M/H = MANHOLE N.A.P. = NOT A PART OF NGVD = NATIONAL GEODETIC VERTICAL DATUM N.T.S. = NOT TO SCALE 0.H.L. = OVERHEAD UTILITY LINES O.R.B. = OFFICIAL RECORD BOOK O/S = OFFSET OVH. = OVERHANG P.B. = PLAT BOOK P.C. = POINT OF CURVE P.C.C. = POINT OF COMPOUND CURVE PL. = PLANTER P.L.S. = PROFESSIONAL LAND SURVEYOR P.O.B.. = POINT OF BEGINNING P.O.C.. = POINT OF COMMENCEMENT P.P. = POWER POLE P.P.S.. = POOL PUMP SLAB P.R.C. = POINT OF REVERSE CURVE PRM = PERMANENT REFERENCE MONUMENT PT. = POINT OF TANGENCY PVMT. = PAVEMENT PWY =PARKWAY R. = RECORD DISTANCE RAD. = RADIUS OF RADIAL RGE. = RANGE R.P. = RADIUS POINT R.O.E. = ROOF OVERHANG EASEMENT R/W = RIGHT -OF -WAY SEC. = SECTION S.I.P. = SET IRON PIPE L.B. 86044 SWK = SIDEWALK T = TANGENT TWP = TOWNSHIP U.E. = UTILITY EASEMENT U.P. = UTILITY POLE W.M. = WATER METER W.R. = WOOD ROOF W.S. = WOOD SHED = ANGLE Q = CENTRAL ANGLE = CENTER LINE = MONUMENT LINE LEGAL NOTES TO ACCOMPANY SKETCH OF SURVEY ( "SURVEY"); - THERE MAY BE EASEMENTS RECORDED IN THE PUBLIC RECORDS NOT SHOWN ON THIS SURVEY. - THE PURPOSE OF THIS SURVEY IS FOR USE IN OBTAINING TITLE INSURANCE AND FINANCING, AND SHOULD NOT BE - EXAMINATIONS OF THE ABSTRACT OF TITLE WILL HAVE TO BE MADE TO DETERMINE RECORDED INSTRUMENTS, IF USED FOR CONSTRUCTION PURPOSES. AECTING THE PROPERTY. THIS OR EASEMENTS OF RECORD, AND LEGAL RESERVATIONS GAL DESCRIIPTIONS PROVIDED BY CLIENT OR ATTESTING TITLE COMPANY. BOUNDARY COULD BE DRAWN A DR A SHOWN N O AND/OR AGR ! GRAPHIC NOT TO SCALE. OF THE SURVEY WORK PERFORMED IN THE EASEMENTS AS SHOWN ARE PER PLAT BOOK, UNLESS OTHERWISE SHOWN. - THE TERM "ENCROACHMENT' MEANS VISIBLE AND ABOVE GROUND ENCROACHMENTS. - ARCHITECTS SHALL VERIFY ZONING REGULATIONS, RESTRICTIONS AND SETBACKS, - FOR SUBMITTING PLOT PLANS WITH THE CORRECT INFORMATION FOR THEIR APPROVAL FOR AUTHORIZATION TOBLE AUTHORITIES IN NEW CONSTRUCTIONS, UNLESS OTHERWISE NOTED. THIS FIRM HAS NOT ATTEMPTED TO LOCATE FOOTING AND/OR FOUNDATIONS. FENCE OWNERSHIP NOT DETERMINED. - THIS PLAN OF SURVEY HAS BEEN PREPARED FOR THE EXCLUSIVE USE OF THE ENTITIES NAMED. - HEREON, THE CERTIFICATE DOES NOT EXTEND TO ANY UNNAMED PARTY. - THE SURVEYOR MAKES NO GUARANTEES AS TO THE ACCURACY OF THE INFORMATION BELOW. THE LOCAL F.E.M.A. - AGENT SHOULD BE CONTACTED FOR VERIFICATION. THE FNIP FLOOD MAPS HAVE DESIGNATED THE HEREIN DESCRIBED LAND TO BE SITUATED IN ZONE: X COMMUNITY/PANELJSUFFIX: 120662 0093 J DATE OF FIRM: 07117/1995 BASE FLOOD ELEVATION: WA. CERTIFIED TO: RAQUEL WOOLIN CHRISTOPHER P. KELLEY, P.A. OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY no LEGEND TYPICAL —OH- OVERHEAD UTILITY LINES CBS = WALL (CBW) -4--* C.L.F. = CHAIN LINK FENCE I.F. = IRON FENCE W.F. = WOOD FENCE • 0.00 = EXISTING ELEVATIONS SURVEYOR'S NOTES 1) IF SHOWN, BEARINGS ARE REFERRED TO AN ASSUMED MERIDIAN, BY SAID PLAT IN THE DESCRIPTION OF THE PROPERTY. IF NOT THEN BEARINGS ARE REFERRED TO COUNTY, TOWNSHIP MAPS. 2) THIS IS A SPECIFIC PURPOSE SURVEY. 3) THE CLOSURE IN THE BOUNDARY SURVEY IS ABOVE 1:7500 FT. 4) IF SHOWN, ELEVATIONS ARE REFERRED TO MIAMI -DADE COUNTY. BM# ELEV. FEET OF N.G.V.D. OF 1929. SURVEYOR'S CERTIFICATION I HEREBY CERTIFY: THAT THIS "BOUNDARY SURVEY" OF THE PROPERTY DESCRIBED HEREON, AS RECENTLY SURVEYED AND DRAWN UNDER MY SUPERVISION, COMPLIES WITH THE MINIMUM TECHNICAL STANDARDS AS SET FORTH BY THE FLORIDA BOARD OF PROFESSIONAL LAND SURVEYORS IN CHAPTER 81017 -8, FLORIDA ADMINISTRATIVE CODE PURSUANT TO 472.027. FLORIDA STATUTES. BY: GEORGE IBARRA (DATE OF FIELD WORK) PROFESSIONAL LAND SURVEYOR NO. 2534 STATE OF FLORIDA (VALID COPIES OF THIS SURVEY WILL BEAR THE EMBOSSED SEAL OF THE ATTESTING LAND SURVEYOR). REVISED ON: REVISED ON: 1 ft Main Net Mesh Size: Braid: Net Braid Tension Lines Nylon Pulleys Net Strength: Expected life: Installation Fittings Surface Mount Plates Flush Mount Anchor Hook Alternate Anchors 1(;d Sckfe Pool Nets Product Specifications 3.5 Inches (Required to meet ASTM 1346 -91 Standards 100% Polyethylene with UV inhibitors built in. for prolonged lifespan '/4 Inch 3/8 Inch 2 % Inch Body Length Pulley Wheel, 1 Inch diameter, 5/16 Inch width Tested up to 485 lbs for ASTM 1346 -91 standard Between 7 to 10 years 3.5 inch plate with two anchor positions and two screw holes Glass filled nylon for increased resistance to sun and chemicals Available in Grey, Terra Cotta and Beige (cream) % inch diameter barrel with flanges 1.5 inch depth Brass or Glass filled nylon for increased resistance to sun and chemicals Available in Grey, Terra Cotta, Beige (cream) and Brass 4mm Stainless Steel wire hook 1/4 inch x 2 inch Stainless Steel eye bolts 1/4 inch Stainless Steel drop anchors Stainless Steel S- hooks (Gate hook), min .141 x 1.5 inch 3101 SW 3RD AVENUE • FORT LAUDERDALE, Fl 33315-3317 • TOLL FREE1. 866. 463.5700 • F MUM: www.kidsafepoolnetts.com r . :IAV -21 -2002 12:41 Pi'4 K I DSAFE -APPLIED C H LABORATORIE 5371 N.W. 181 at STREET • MIAMI, FLORIDA 33014.9223 Mesita: wraw.eti- tBstcom • Email: arItastiaal.corn PH. (305) 824.4900'• FAX: (305) 624.3652 954 April 11, 2001 Mr. Kim Nothard President Kid Safe Pool Nets 215SW14Way Fork Lauderdale, FL 33312 RE: L/N30137 Dear Mr. Nothard: This letter is regarding the safety testing of your Pool Safety Net. As you l ntiw, (Ws testp rt successfully completed. The safety net was tested to assure compliance with ASTM F- 1346 -91, Standard Peffaanall s for Safety Covers and Labeling Requirements for All Covers for Swibmhtg Pools, Spas and >`iot Tubs' the work was performed under the above referenced ARL file number. The model that was tested and found to comply with the standard is trade. ` 1 i4 Safe." This latter' serve as confirmation that these units are Listed by ARL effective March 20, 2001 and you are authorized to label your products with the ARL Listing Mark. Your Certification Report and Follow-up Service Pmccdurc are in the process of being finalized and be forwarded to you upon coazplettion. If you have any questions, please do not hesitate to cotes Cordially, Alan B. 5 ert Director of Engineering ABS/in TESTING FOR CONSUMER SAFETY SAE-!:TTY As SeZt7:40.1V, 'k l STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number PART II - SITEPLAN Scale: Each block re • resents 10 feet and 1 inch = 40 feet. �► ■rlrrrommu m ammul , rl■Irlrlmas r ■rrrrr�rrrrrrMMINIM r�Arrrrrrrr MOMMINNOMMEMMOMMEMEMMEMMEMMEMMM ■rrrrrrrrrrr iMM o MMEMEMrrrrrrrr ■rrrrrrrr ■rr /'%I irr rrrr rMrrrrrrrr ■rrrrrrrr ■rrEMrrr rrrr rU ■rrrrrrr INIMEMEMIMMEMMINIMMEEMMINIMEMMINIM ■rrrrrrrrrrrrIUMMOrrr IMMEMOrrr ■IrrrrrrlEM ■rrrr rrrr INI rrrrrrrnr ■ ■rrrrrr�t rrrrMFBM :rrr rrrrrrrrrr ■rrrrrrrU ■MEMMEOMr rrr rrrrrrrrrr MINIMMEMMMEMMUMMMEMMENIMMEMMUMEM MINIMMEM0CEMMUMMEMOMMEMMEMMINIMEM .1..!!........ »..I..(imm ►mmommummil rMONOMMErrrrrrrErrrrr`rtrrrrrrrrr E Mr`riOMMEM 1 INMErrOrrrrrrrrrrrrrrr ■EMMINIrrr rrrrrr M ■rrrr rrrrrrrrr■ ■rrrlrrrlrrrrrrrr N rlrrrr rrlrrrrrrrr ■■Irrr■rrurummurrmo rrrlrrr limn ■rrrrrrrrrrrr mmom rrrrr miimr mammummormimmummommummomm Notes: `i-8`31 5 Cne-c.w -t . Plan submitted by Plan Approved By County Health Department GLI 5401 1,5 U3(2)( -°"►1 a'10 It S 41 Yu.) pproved Date ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT DH 4015,10/86 (Replaces HRS-H Form 4016 which may be used) (Stock Number: 5744 - 002 - 4015 -6) Page 2 of 4