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MC-11-1727P 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 C\ Inspection Number: INSP - 164676 Permit Number: MC -9 -11 -1727 Scheduled Inspection Date: October 19, 2011 Inspector: Perez, JanPierre Owner: JONES, WILLIAM Job Address: 379 NE 94 Street Miami Shores, FL Project: <NONE> Contractor: BIMINI BREEZE HVAC INC Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1132060136130 Phone: (305)968 -4205 Building Department Comments INSTALL 1 1/2 TON SPLIT SYSTEM IN PLACE OF 2 TON PACKEGE. PLACE AH IN UTILITY ROOM WITH THREE VENTS TO KITCHEN, DINING ROOM AND UTILITY ROOM. 2--672 I / Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. October 18, 2011 For Inspections please call: (305)762 -4949 Page 6 of 21 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 RECEIVED SEP 2 2 nil BY: Permit No. tr/C l I —r-71 vC Master Permit No. Permit Type: MECHANICAL OWNER: Name (Fee Simple Titleholder): Ili 1 l.L t A !Jb 3 . LTb k E S Phone #: 30.S° 8"7 7 - a45b Address: 371 e- 94 `r City: PrItR tls I a- ri ices State: f Zip: 3 t 3 it Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: 37 ot E q4 . City: Miami Shores County: Miami Dade Folio/Parcel #: (t - 3 2 a D L 3° 3( zip: 33 t Is the Building Historically Designated: Yes NO V Flood Zone: CONTRACTOR: Company Name: Address: 10 t 0 NI 13-1- r -P,cr CG Phone #: A1.gS- City: State: rL_ Zip: Qualifier Name: 1 State Certification or Registration #: CAS 1 `6 3 Phone #: Certificate of Competency #: Contact Phone#: OA "Igor Email Address: DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: Type of Work: Address Description of Work: J.A1 �r Square/Linear Footage of Work: DNew epair/Replace UDemolition 11210 Se rr &iteration S e �, del i ees* *** * * ** * * * * * * * * * * * * * ** t * * * * * * * ** * * * * * ** CCF $ °' -CO /CC $ DBPR $ Bond $ Technology Fee $ Submittal Fee $ Scanning Fee $ Notary $ Double Fee $ Permit Fee $ Radon Fee $ Training/Education Fee $ Structural Review $ TOTAL FEE NOW DUE $ 41-'9 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 Owner The foregoing instrument was acknowledged before me this ,p2 / Signature- Contractor The foregoing instrument was acknowledged before me this day of 9 , 0 IL, by (/+il.t_ .PHe ® 3 - 3® s`S, day of , 20 (.1 , by U TI t� � who iCersonally known to me o who has produced who is personally known to me or who has produced t 49 `` As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: Sign: L. :'LL Print: it x f" L My Commission Expires: * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED BY �Nf HEATHER L. LOPES Notary Public • State of Florida .g My Comm. ExWir1S Oct 13, 2013 V\ 1\ <. Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) NOTARY PUBLIC: Sign: Print: My Commission Expires: owl I 11 L06S9ii r' # twiggiwwp3 - �I1�fldM 1ON Zt0Z1901E0 Zoning Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): 3? 9 L) c_ 9 4 City: Miami Shores Village County: Miami Dade Zip Code: "3 t ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS /ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES E NO El ARHI Sheet Attached: YES NO ❑ Contract Attached: YES UNIT BEING REPLACED DATA NEW UNIT iciettnei ® MANUFACTURER j p ,3/0 O /m- AHU or PKG. UNIT MODEL # COND. UNIT MODEL # V KW HEAT NOM TONS / 7, AHU CU PKG ®5 1) M.C.A AHU CU PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG ,- *f® 3) VOLTS AHU CU PKG PKG UNIT / / PKG UNIT / / // EER/SEER YES NO REPLACING DUCTS ►' NO YES NO REPLACING THERMOSTAT a y NO YES NO NEW 4 "CONCRETE SLAB .. E ..�' NO YES NO NEW ROOF STAND YES YES NO NEW RETURN PLENUM BOX YES 41 • 1. Minimum Circuit Ampacity (Wire Size): / 0 krf//' 2. Maximum Overcurrent Protection (Fuse /Breaker Size): 6- 3. Voltage of Circuit (208/240/480): P"V 0 c 4. Size Disconnecting Means: Contractor's Company Name: Il & / t1 - Phone: 30,E iW004 State Certificate or Registration N. nrite, 3 99 Certificate of Competency N. Signature (Qualifier'/ Ignature only) Date: Ii MIAMI -DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 1st FLOOR MIAMI, FL 33130 648472-9 BUSINESS NAME / LOCATION BIMINI BREEZE HVAC INC 7010 NW 169 ST 33015 UNIN DADE COUNTY 2010 LOCAL BUSINESS TAX RECEIPT 2011 MIAMI -DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2011 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 THIS IS NOT A BILL — DO NOT PAY RENEWAL RECEIPT NO. 675452-8 STATE# CAC1816329 OWNER BIMINI BREEZE HVAC INC Sec. Type of Business THIS IS ONCY'A ggLC MECHANICAL CONTRACTOR BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE HOLDER'S QUALIFICA- TIONS. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/23/2010 60040000169 000075.00 SEE OTHER SIDE Ac# 090222 FIRST -CLASS U.S. POSTAGE ; ' PAID MIAMI, FL PERMIT NO. 231 WORKER /S 1 DO NOT FORWARD BIMINI BREEZE HVAC INC JUSTIN P ROMER PRES 7010 NW 169 ST HIALEAH FL 33015 fl,iIIIIII,Il,i i, pl#, I�luiIIII IiiIIIIiI,Iii7II11ilii,I 6111 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEQ# 7,10081201678 08/12/2010 LICENSE NBR 107007360 CAC1816329 The CLASS B AIR CONDITIONING C Named below 1S CERTIFIED Under the provisions of Chapte# Expiration date: AUG 31, 2012 ROMER, JUSTIN P �` x BIMINI BREEZE HVAC INC 7010 NW 169TH STREET HIALEAH FL 33015 DISPLAY AS REQUIRED BY LAW CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYY) 08/26/11 PRODUCER Annette Willis Insurance 4759 N.W. 183rd St. Miami, FL 33055 Phone (305) 625 -8131 Fax (305) 625-3694 INSURED BIMINI BREEZE HVAC INC. 7010 NW 169 St MIAMI, FL 33015- (305) 968 -4205 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT FICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIC ES BELOW. INSURERS AFFORDING COVERAGE INSURER A: GRANADA NAIC # INSURER B: INSURER C: INSURER D: INSURER E: THE POLICIES 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER Pam'', MM/DD/YYYY POLICY A MWDD/YYY WYY) LIMITS A ❑ GENERAL LIABILITY ❑ COMMERCIAL GENERAL LIABILITY ❑❑ CLAIMS MADE ❑ OCCUR ❑ 0185FL00028937 08/26/2011 08/26/2012 EACH OCCURRENCE $1,000,000 DAMAGE RENTED PREMISES ( (Ea occurrence) $50,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $ 2,000.000 ❑ PRODUCTS - COMP /OP AGG $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PROJECT ❑ LOC ❑ 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 EXCESS / UMBRELLA LIABILITY ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE Y/N OFFICER / MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under SPEIAL PROVISIONS below ❑ WC STATU- ❑ OTH- TORY LIMITS ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY UMIT OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS AIR CONDITIONING CONTRACTOR CANCELLATION MIAMI SHORES VILLAGE 10050 NE 2 AVE MIAMI FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATET EREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30_ . --TiAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY • F ANY KIND UPON THE I • URER, I S AGENTS REPRESENTATIVES. AUT' • -. D REPRESE T TIVE ACORD 25 (2009/01) QF - . . Th ACRD name and logo are registered marks of ACORD 06 -27 -2011 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO 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: 08/20/2011 EXPIRATION DATE: 08/19/2013 PERSON: ROMER JUSTIN P FEIN: 371574398 BUSINESS NAME AND ADDRESS: BIMINI BREEZE HVAC INC 7010 NW 189TH STREET HIALEAH FL 33015 SCOPES OF( BUSINESS OR TRADE: 1- CERTIFIED AC CONTRACTOR 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 , certif (cote to meet the requirements of this section. QUESTIONS? (850) 413 -1609 IWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 IM .14- , - • - L -10 ^( i 'oNaS / 3-7:1 /lam 91/7-457- �ftg2 r- r /cryo�(L Wall /654* ipamgw3 SEP 2 2 2011 (ji:LI f&Arrn 1Y TOIj Aqk Fx DN Foi 1-roo rno t r- Miami Shores Village APPROVED BY DATE ZONING DEPT LDG DEPT j`N /I■ 1 IRT.iFCT TO COMPLIANCE WITH ALL FEDERAL ! Al I- AND COUNTY RULES AND REGULATIONS /t4 r. Plik I I (913Nf -ol ,00o "'LAPP .-u ..-1 iCERTI FIE D Www.a tridirectory,org_" This combination qualffies for a Federal Energy Efficiency Tax Credit when placed In service between Feb 17, 2009 and Dec 31, 2011. Certificate of Product Ratings AHRI Certified Reference Number: 3632448 Date: 9/22/2011 Product: Split System: Air - Cooled Condensing Unit, CoII with Blower Outdoor Unit Model Number :116BNA018'" `*B Indoor Unit Model Number: FX4DNF019 Manufacturer: BRYANT HEATING AND COOLING SYSTEMS Trade/Brand name: LEGACY RNC 16 PURON AC Manufacturer responsible for the rating of this system combination is BRYANT HEATING AND COOLING SYSTEMS Rated as follows in accordance with AHRI Standard 210/240 -2008 for Unitary Air- Conditioning and Air- Source Heat Pump Equipment and subject to verification of rating accuracy by AHRI- sponsored, independent, third party testing: Cooling Capacity (Btuh): 18000 EER Rating (Cooling): 13.00 SEER Rating (Cooling): 16.00 " Ratings followed by an asterisk (1 indicate a voluntary rerate of previously published data, unless accompanied with a WAS, which indicates an involuntary rerate. DISCLAIMER AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warrarrties or guarantees as to, and assumes no ref for, the product(s) listed on this Certificate. AHRI expressly disclaims all Bablllty for damages of any kln d arising out of the use or performance of the product(s), or the unauthorized alteration of data Bated on this Certitk at®. Certified ratings are valid only for models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS This Certificate and its contents are proprietary products ofAHRL This Certificate shag only be used for individual, personal and confidential reference purposes. The contents of this Certificate may not, in whole or In part, be reproduced; copied; disseminated; entered hrto a computer database; or othervrlse utilized, In any form or manner or by any means, except for the user's individual, personal and confidential reference. CERTIFICATE VERIFICATION LItir The Information for the model cited on this certificate can be verifkxl at www.ahridirectory.org, A Air- Conditioning, Heating, click on "Verify Certificate" link and enter the AHRI CertMed Reference Number and the date on EIM and Refrigeration Institute which the certlflcaie was Issued, which is listed above, and the Certificate No., which Is listed below. ©2011 Air - Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 129611453650911203 ECK LIST ITEM OR PART DESCRIPTION PRICE flIPRESSER IUCTION PS PSI, BIIUMINI BREEZE HVAC INC Commercial • Residential Air Conditioning Services Inc. 7010NW169St Hialeah FL 33015 Ph 305 - 968 -4205 anizorin LAST Manufacturer Warranty Company Guarantee 0 service Agreement O Repairs 0 Tune - Up 0 Residential 0 Commercial PPI. Duct. Repairs 0 Air Conditioning CH nr,: Refrigeration Sanitizing Installation MODEL PHONE 8 DESCRIPTION OF WORK 1'.tNS1?ECTt(1 to INSPECT'& rj AIR FiLTE F.l CLFANE0 I4 C.1 'HEAD E. ei 8tJJRksiE` FUEL $t P TOTAL PART PARTS WARRANTY..__ ,..,- Ail parts recorded are warranted as per manufacturer specltications. LABOR GUARANTY The labor charge es recorded here relative to the equipment serviced as noted, is guaranteed for a period of days. We do not. ofcourse. guaranty other parts than those we Install. If repairs later become necessary due to other defective parts, they will be charged separately. ITEM # REPAIR ESTIMATE ENVIRONMENT TYPE REFRIO RECOVERED? RECYCLED? RELCAIMED? RETURNED TO jat SYSTEM? YES NO J.c H WRITE OR CODE AMOUNT O M REFR MACH USAG E OTAL OTHER CHARGES CHECK LIST LABOR CHARGES HRS. @ /HR. TECHNICIAN SIGNATURE CERT. TOTAL OTHER SYSTEM QTY CITY- E 0 U 1 M E N T CHARGED OUT (OR REPLACED)? DIS- MANTLED? YES NO 0 YES NO I:ERNiS: DUE UPON COMPL:_TiON I HAVE THE AUTHORITY TO ORDER THE ABOVE WORK AND DO SO ORDER AS OUTLINED ABOVE. IT 18 AGREED THAT THE SELLER WILL RETAIN TITLE TO ANY EQUIPMENT OR MATERIAL FURNISHED UNTIL FINAL & COMPLETE PAYMENT IS MADE, AND IF SETTLEMENT IS NOT MADE AS AGREED, THE SELLER SHALL HAVE THE RIGHT TO REMOVE SAME AND THE SELLER WILL BE HELD HARMLESS FOR ANY DAMAGES RESULTING FROM THE REMOVAL THEREOF. TRIP CHARGE TAX OUR PERSONNEL RECOMMEND: 1 i TIME.ARRIVED TIME DEPARTED C.S. B D7,2'. ^"17,,.177 :. NON USABLE O DISPOSAL 0 YES NO QTY OWNER'S INITIALS ACCEPTED DECUNED AUTHO 4 0 TOTAAL.. AMOUNT ABOVE ORDERED WORK HAS BEEN COt& tETEy AdD i X RECEIPT OF MY COPY. DATE Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 165626 Permit Number: EL -10 -11 -1830 Scheduled Inspection Date: October 19, 2011 Inspector: Devaney, Michael Owner: JONES, WILLIAM Job Address: 379 NE 94 Street Miami Shores, FL Project: <NONE> Contractor: CARIBBEAN ELECTRICAL CONTRACTORS INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1132060136130 Phone: (954)562 =0377 Building Department Comments HOOK UP SERVICE FOR NEW NC SYSTEM INSTALLATION Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. October 18, 2011 For Inspections please call: (305)762 -4949 Page 20 of 21 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fag: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit No. Master Permit No Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): w e --L' Ate 3 • 3c is S Phone#: 305° $"l7' a4 5� Address: '5? 4 LIE q 4 Tg e'-Tr-- City: en 1 ANA. ST +0 Q S State: lam_ Tenant/Lessee Name: Finail t&. t:.L*.b. r‘ . ; e.D JOB ADDRESS: 3-2 q E 4 4 -- City: Miami Shores County: Miami Dade Zip: 3 3 13 8 Folio/Parcel #: t't - 3 20(0- ®l •3- LP 1 3 CD Is the Building Historically Designated: Yes NO Ve Phone#: 1,5 caAr'q . C Zip: 33 1.38 Float. Zone: CONTRACTOR: Company Name: L t4t4 � �ci1 - Pne#: ft)-3,-,s--6a - 0 3 °77 Address: **7 p k Fl zip: 330 1, City: jt%, y Qualifier Name: L a dA-tk,e1 X( c_166N3 LA Phone#: A .—t State Certification or Registration #: (3 0 (-(Q ` Certificate of Competency #: Contact Phone#: ,SAist.e._ Email Address: P Let -1(J ecuei [ .. col i i DESIGNER: Architect/Engineer: Phone#: State: Value of Work for this Permit: $ 414.41) Square/Linear Footage of Work: Type of Work: Address ❑Alteration UNew ❑R air/Repiace Description of Work: Mukc- S— Pe-U-S k.„ ❑Demolition Submittal Fee $ 3- ° Permit Fee $ / '"i ®' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ Ia TOTAL FEE NOW DUE $ D 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 11 be deliver to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commence must be po . e % at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the e of suc posted notice, the inspection will not be ap;roved and a reinspection fee will be charged. Owner The foregoing instrument w. �knowledged before me this " The fo day of 20 11 , by W I ArM. Y o To o..e"S, Signature nally known to me r who has produced wh NOTARY PUBLIC: tification and who did take an oath. Sign: c �� Print: 144er-t Contractor trume i t was acknowl . A, g- + before ,1- , 20 it, b .��, (]_AL .. I e or who has produced-Ott cation and who did take an oath. 5 My Commission Expires: * *** * * * **** **a*s,** ** APPROVED BY A•-"Noi� — • HEATHER L. LOPES Notary Public - State of Rodda 4x. eelfiNefiPleeleePitte.* nit% Commisston # DD 932828 pig******************** * ** * * ** * * * * * * ** * *** * ** * * *** ** — 7ffiliner Structural Review (Revised 07 /10107)(Revised 06/lo/2009)(Revised 3/15/09) Zoning Clerk (tit 11111111LegoiL !i��► � �� 1 _ i , ,�°!9W 1111■ 1111 Inill•TIVAII ■1111.1■■ ■ • • ■I 11 11x1, 11111.416 l ..FIIJI,�ir�►ElA�i,►, P, --.. 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