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RC-10-564Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 149351 Permit Number: RC -4 -10 -564 Scheduled Inspection Date: July 27, 2010 Inspector: Rodriguez, Jorge Owner: PAULSEN, CARL Job Address: 400 NE 101 Street Miami Shores, FL Project: <NONE> Contractor: ORONI INC Permit Type: Residential Construction Inspection Type: Final Building Work Classification: Alteration Phone Number (305)754 -9370 Parcel Number 1132060170480 Phone: (305)685 -0412 Building Department Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments July 26, 2010 For Inspections please call: (305)762 -4949 Page 20 of 25 Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795 -2204 400 101 Street Miami Shores, FL Expiration: 10/06/2010 CARL PAULSEN 1132060170480 Block: Lot: 400 101 Street MIAMI SHORES FL 33138 CARL PAULSEN Contractor(s) ORONI INC Phone Cell Phone (305)685 -0412 (305)754 -9370 Valuation: Total Sq Feet: $ 4,000.00 60 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: BATHROOM Stories: Front Setback: Left Setback: Bedrooms: Plans Submitted: Certificate Date: Bond Retum : Occupancy: Exterior: Rear Setback: Right Setback: Bathrooms: Certificate Status: Additional Info: Classification: Residential Fees Due CCF DBPR Surcharge Education Surcharge Permit Fee - Additions/Alterations Radon Surcharge Scanning Fee Submittal Fee Technology Fee Total: Amount $2.40 $0.30 $0.80 $120.00 $0.30 $3.00 $50.00 $3.20 $180.00 Pay Date Pay Type Invoice # RC -4-10 -37492 04/02/2010 Credit Card 04/09/2010 Credit Card Amt Paid Amt Due $ 50.00 $ 130.00 $ 130.00 $ 0.00 Available Inspections: Inspection Type: Final PE Certification Shutter Final Window Door Attachment Tie Beam Slab Termite Letter Framing Insulation Drywall Screw Shutter Attachment Window and Door Buck Gelling Grid Fill Cells Columns Declaration of Use In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. April 09, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date April 09, 2010 1 Miami Shores Village tra3RW30 Buildin g Department artment 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING PERMIT APPLICATION FBC 2004 Permit Type (circle): Building Owner's Name (Fee Simple Titleholder) Owner's Address Cit pk . .�, � 5 State Tenant/Lessee Name HY.... Permit No. R C 100 Master Permit No. Electrical (Plumbing Mechanical Roofing ( -f. Phone # C).SJ ? - % 37C? FL_ Zip 'j Phone # Job Address (where the work is being done) City Miami Shores Vi11aje County FOLIO / PARCEL # "C a O[- Is Building Historically Designated YES Contractor's Company Name Contractor's Address City •pv � P, . . Qualifier Name ©fkas,A0 Miami -Dade 0 NO Zip Phone #(c5—) C — S=df1- State &ca S State Certificate or Registration No. C j Z Zip 331 Phone # Architect/Engineer's Name (if applicable) Value of Work For this Permit $ Type of Work: DAdditio i DAlteration []New Describe Work:: Certificate of Competency No. Ck, 001 3 Phone # Square / Linear Footage Of Work: yl Repair/Replace D Demolition * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * ** *Fees * * * * ** oae Submittal Fee $53 .00 Permit Fee $ Notary $ Training/Education F 0 ° .D Scanning $ 0 ` C` '49)' Radon $ Bond $ Code Enforcement $ * * * * * * * ** + * * * * * * * ** * ** * * *** * * * * * ** CCF $ 9 ° ` C CO /CC Technology Fee $ rd Zoning $ Double Fee $ Structural Review. $ Total Fee Now Dui See Reverse side —> Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS. and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection wh• h occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will -' of . ap ro ed and a reinspection fee will be charged Signature Owner or Agent The foregoing instrument was acknowledged before me this 2- day of j�tuM , 20 10, by Ozta.. who is personally known to me or who has produced 5u. 'Dl. •' P125•121r-(03-M— 0 As identification and who did take an oath. NOTARY PUBLIC: DISI 1'00 ONiaNOIr OISw nv iiam a twos ZIOZ Ol: '?I�7L1T :sandxa ,...�,.,,,, 9 2 .9 % Q uotSS11Ut 1S-OrIgfld A2iV.L0N Sign: Print inn' My Commission Expires: �� !� N Signature Q� Contractor The foregoing instrument was acknowledged before me this 7— day of '4(211- C� by 0 titn e-o (6 C 'S i' S who is ersonally known me or who has produced as identification and who did take an oath. ed .a APPLICATION APPROVED BY: (Revised 02/08/0 VRY PUBLIC: NOTARY WITL.47 1w o fission ��,s. ez ,r*.* * *,�*t ** ** *,tit *,7 56 * *,ti:**** s 10, 2012 ,.NDLN060.,MC, Plans Examiner Engineer Zoning MC -STATE or ?'!:ORIDA 2012 9 BONDh.. Permit Number: EL -4 -10 -566 J Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 148448 Inspection Date: July 14, 2010 Inspector: Devaney, Michael Owner: PAULSEN, CARL Job Address: 400 NE 101 Street Miami Shores, FL Project: <NONE> Contractor: ATLANTIS ELECTRICAL CORP Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number (305)754 -9370 Parcel Number 1132060170480 Phone: (305) 551 -4043 Building Department Comments July 14, 2010 For Inspections please call: (305)762 -4949 Page 1 of 1 Passed Inspector Comments f F72.- /4/ j7/i>V/O Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until July 14, 2010 For Inspections please call: (305)762 -4949 Page 1 of 1 Protect Address Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 400 101 Street Miami Shores, FL Owner Information Parcel Number Applicant Address 1132060170480 Block: Lot: CARL PAULSEN Phone Cell CARL PAULSEN 400 101 Street MIAMI SHORES FL 33138 (305)754 -9370 Contractor(s) ATLANTIS ELECTRICAL CORP Phone Cell Phone (305) 551 -4043 Type of Work: BATHROOOM Additional Info: ELECTRICAL Classification: Residential Fees Due CCF DBPR Surcharge Education Surcharge Permit Fee - Additions/Alterations Radon Surcharge Scanning Fee Submittal Fee Technology Fee Total: Amount $1.20 $0.30 $0.40 $150.00 $0.30 $3.00 $0.00 $1.60 $156.80 Pay Date Pay Type Amt Paid Amt Due Invoice # EL-4-10 -37494 04/09/2010 Credit Card $ 156.80 $ 0.00 Available Inspections: Inspection Type: In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. April 09, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date April 09, 2010 1 NiU 1 ILL Ur LUIVIIVitiNkitiVitr4 I A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO.__ _TAX FOLIO Nan, 5zet. or+-011-go STATE OF FLORIDA: COUNTY OF MIAMI-DADE: 111111111111111111111111111111111111111111111 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. CFI 2010R0221741 OR Bk 27237 Ps 2375; (113s) RECORDED 04/02/2010 125925 HARVEY RUVIN? CLERK OF COURT NIAMI-DADE COUNTY? FLORIDA LAST PAGE 1. Legal description of property and street/address:At_a' .fmkis_ufge.les cec P45 is-lit termzeig PS tot $77 JAtii•mk- 5_1WCS. '3.317ff 2. Description of improvement: _Blryhee-z."-_aOQ—_ • 3. Owner(s) name and address: _C#11(4___ Interest in property: .. _ Name and address of fee simple titleholder: 4. Contractor's name and address: ___0(2■3( 1.__f.)1A5 &Cr itAk._15714-4-1 fz _3314. T- 5. Surety: (Payment bond required by owner from contractor, if any) Name and address: Amount of bond $ 6. Lender's name and address:._ 4 ti _I-04213"Ltiole CrArri 616" 1,_ 0■_ 001 ; r9, CirThirC4W1:Ulke_ 7. Persons within the state of Florida designated by Ownetagglaitar4 - er documents may be served as idwie my, 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 d Si 'ratio z a fere d. 0 lik.°4f e of this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a specified) _ ure of Owner Print Owner's Name,O,Atit-c-,, Perk.44 Ok-1 Sworn to and subscribed before me this day of , , 20 10, Notary Public Print Notary's Nam My commission ex 1 23.01 52 PAGT d 1 tOld A10.! [IA C CY Ig eS1‘ Cornmission#DD535535 ' xpires .„ MAY 13, 2010 Bonded Thru Adendo Bonding Co., Inc. Prepared by Address: De4,31 ti-tp-fq ft- -77t& t. tu.D (300W fY1 I. cri c • • • Cr, CZ. i---)/9771 sNou_trin oar a NV S3lf1P Nr"1"-.0 (]NV 1191=1302d TIV H_LIAA ONNfrldIA100 i_oDr9ns 1d30 0015 1 tro.t.-k IA • aLVG _LdJO ONINOZ Ae C; A 0 :73 cAT eC,2111A saJois conSolt-e.... DOG ,c • • • • • • • • • • • • • • • • 0. • • • • • • .4 -• • • 44!. • •=.1. • • • T• :)9 • • otoz o >la lai&rxam • • • • • • • • • • • • • * • • • *0 • -.4 • • • • • * ti, .t1 '^ ,..4 • • • • • • • • • • • • • • • • • • • • • • • • ... •• • • • •• •• • A_.•_• •...... • • .. • Ai- - Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Permit No. 1 L 10-5(4 Master Permit No. g G I 0 ' • BUILDING PERMIT APPLICATION FBC 2004 303EWIER APk Q ?l BY: i cieht01041diCi• Permit Type: Electrical Owner's Name (Fee Simple Titleholder) EVv Phone # Owner's Address --- __t City .t ,( S k - xz 3 State P2 Tenant/Lessee Name E- MAIL: Job Address (where the work is being done) City Miami Shores Village FOLIO / PARCEL # It ap° O) 1 - Is Building Historically Designated YES Zip 33(38 Phone # County Miami -Dade Zip (3 NO Contractor's Company Name Contractor's Address MOM c, , ' Z L City NA tA-, State ?.0 Phone # '391' 6 790 Zip -31 Ls- Qualifier Name fAilktoce.s co Phone # State Certificate or Registration No. EC t 30o' ig -Si &Gib E -MAIL: Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ Type of Work: Describe Work: ['Addition ['Alteration Square / Linear Footage Of Work: ❑New ❑ Repair/Replace ❑ Demolition ***** * * *xxxxx * * * * * * * * *. * * * * * * * * *. * ** Fees*.** o: dc****. * **** ********w*x*xxxxw****** ** ** Submittal Fee $ Permit Fee $ 14.154 CCF $ \ • 253 CO /CC Notary $ Training /Education Fee$ % t) Scanning $ '3 Bond $ Structural Review. $ Radon $ • - DPBR $ Code Enforcement $ Technology Fee $ Double Fee $ 1 tot 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. [ 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject :o attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first ''.:: ctio h occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection 'ill n• t be ed and a reinspection fee will be charged. win ppro Signatur- ,L Owner or Agent The foregoing instrument was acknowledged before me this 2- day of ,P041- , 20 to , by &`'t. 034,1.4e#-' who is personally known to me or who has produced F. W `?'5- 12-1i -63 -211- s identification and who did take an oath. NOTARY PUBLIC: lam to %mos onsond.v am. (Tara eIOZ `OI '2iYy1i :saaidxg '}g 699LcIQ # ttojsslunno3 aaoloQ Vo W QL� (14, ams-Oi arks X2Ii+L()M Sign: Print: My Commission Expires: xxxxxxwww9e .Y********eY*********** **k APPLICATION APPROVED B (Revised 02/08/06) Contractor The foregoing instrument was acknowledged before me this -2- day of AQQ )t- , 20 (t.9 , by CI &' who ':. Ana y know .. me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: --1)3.0i- LQCI uojtzt� Print: w , O'j sawojoQ ssttu '........... My Commission Expire s O' 3E ' .LvJ:s-3fIfinld A lV1OK nk****u$ cac**********X a4****xxxxxxaYoY*****'******** Y**** * x9cdc*****9exie9caY********* oflruascn �I).M �avnxnsasaxou grz I, Ouoq. Plans Examiner Engineer Zoning Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 139676 Permit Number: PL -4 -10 -567 Scheduled Inspection Date: July 21, 2010 Inspector: Hernandez, Rafael Owner: PAULSEN, CARL Job Address: 400 NE 101 Street Miami Shores, FL Project: <NONE> Contractor: NELMAR PLUMBING INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number (305)754 -9370 Parcel Number 1132060170480 Phone: (305) 261 -3942 Building Department Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments July 20, 2010 For Inspections please call: (305)762 -4949 Page 3 of 17 Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Owner Information CARL PAULSEN Address 400 101 Street MIAMI SHORES FL 33138 Phone (305)754 -9370 Cell Contractor(s) NELMAR PLUMBING INC Phone Cell Phone (305) 261 -3942 Valuation: Total Sq Feet: Type of Work: BATHROOM REMODEL Type of Piping: PLUMBING Additional Info: Bond Retum : Classification: Residential Fees Due CCF DBPR Surcharge Education Surcharge Permit Fee - Additions/Alterations Radon Surcharge Scanning Fee Technology Fee Total: Amount $1.80 $0.30 $0.60 $150.00 $0.30 $3.00 $2.40 $158.40 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -4-10 -37495 04/09/2010 Credit Card $ 158.40 $ 0.00 $ 2,200.00 60 Available Inspections: Inspection Type: Top Out Re Pipe Main Drain Heater Water Service Final Water Main Lavatory Underground In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy April 09, 2010 Date April 09, 2010 1 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING PERMIT APPLICATION FBC 2004 Permit Type: Plumbing Owner's Name (Fee Simple Titleholder). Ownerr'ss Address City d\. -,l bJ S e`e_3 State r o APR - ee...5:4''' Permit No. ) 0 a77 Master Permit No. ?PI/Lc Oki Phone # Tenant/Lessee Name E -MAIL: Job Address (where the work is being done) Zip 73 /3 6 Phone # City Miami Shores Village County Miami -Dade FOLIO / PARCEL # it x;10(0' 0 Oq-� Zip 3313 Is Building Historically Designated YES NO x Contractor's Company Name L ► r 41Z L/1ti►,18( q Phone # /\J& J Contractor's Address . 4 9 5-if Sa) 7f it VE City V v I AWL( State PC Zip 3 3! �Y Qualifier Name `-1 5 f 12_00 i vE7, Phone# 30 Jam- 26-/ -3 iv 2_ State Certificate or Registration No. I, Fou 3 $2p (2 Certificate of Competency No. (7 0000 <5W I E -MAIL: Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $°)...1200%. Square / Linear Footage Of Work: Type of Work: ❑Addition ['Alteration °New Describe Work: -� � L � n j j ¢ Dcz_ 0 Repair /Replace Demolition ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ /IV CCF $ Notary $ Training /Educ do F $ . Scanning $ o Radon $U • DPBR $ 0 Bond $ Code Enforcement $ Structural Review. $ CO /CC ethnology Fee $. • 90 Zoning $ Double Fee $ Total Fee Now Due See Reverse side -+ Bonding Company's,,Name (if applicable) Bonding Company's rtddress City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City Zip 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 11 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 i occurs seven (7) days after the building permit is issu i. In the absence of such posted notice, the inspection w no be dF prov: d and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this day of V , 20 �� (t_�, by 6L(. who is personally kno* to me or who has produced F b L • PZS- 124:43-2114s identification and who did take an oath. 2---- NOTARY PUBLI ru'•oo manna =win nuxa ammo I0Z `0I ' ivIK :sa.ndxa �,.t •; 9S 9LGU # IINssIt IIO3 c`. I% Sign: Print: ` b(eQQS. My Commission Expire'S: aYxxx **************ar*, **** eY*** xxxxxxaYdr****xaYxxxrxxxxxxaYx* uxxxxxxxxxxxx* * **** Signature Contractor The foregoing instrument was acknowiedged before me this 1' V day of 001-11-Cif , 20 1O, by L vis r 04gi 'S tt Z , who is personally known to me or who has produced as identification and who did take an oath. NOTARY '_. ;:, IC: Sign: Print: My Commission APPLICATION APPROVED BY: (Revised 02/08/06) YfrAl Plans Examiner Engineer Zoning