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DS-11-973Miami 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 No. 1 l — ( 1 Master Permit No. Permit Type: BUILDING ROOFING OWNER: Name (Fee Simple Titleholder): % 6 u./.' �✓ Phone #: s '76 Z - ?7 /9 14-1/ 7/ /V6 !03 e2. City: » n , `j ete Address: State:L Zip: 23 l3 A Tenant/Lessee Name: /'` Phone #: Email: JOB ADDRESS: 47/ VG /0 3 a i 5-7,-,,, e� City: Miami Shores County: Miami Dade Zip 33 13 S Folio/Parcel #: Is the Building Historically Designated: Yes CONTRACTOR: Company Name: Address: Q, 73 2,, S LA-9 . City: AL"?//i1-404/ Qualifier Name: NO Flood Zone: e9 1 In e 1 t •� I �n? ,.ate p 542 7.- AA- d �� Phone #: 3 ©S" 6;o 7 x'39 O State: P_ . Zip: 3 Phone #: 3pS 4 7 (3 9 0 Certificate of Competency #: 9'8" (rl ® O e 4 /ts/ -wcD State Certification or Registration #: Contact Phone #: 7E34., C(' , - g q c ' Email Address: (E 1A:re, . a y e_77- DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ 126. Square/Linear Footage of Work: c 0 ‘"--O �r Type of Work: ❑Addition OAlteration ONewepair/Replace ODemolition Description of Work: 4-6 p `i �% CASE? ��,� g r E V i S71..i )- re., v Al • ******+ x******* *+ x**********x:**** ******** Fees**************** ******************* ****+xa *** Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ 2o() CCF $ ,CO/CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 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 op. Owner or Agent The foregoing instrument was acknowledged before me this .26'11" day of 1Q7 , 20 I/ , by I 11. who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Signature Contractor The foregoing instrument was acknowledged before me this day of OS 117 , 20 `1 , by -5/0 szi .2of-q, who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: M °'•MMISSION #DD760150 EXPIRES: March 16, 2012 `'4/ 0,,,01.9 BondedThni Budget Notary bribes Print: My Commission Ex JORGE YERO MY COMMISSION # EE082197 fAV EXPIRES April 10, 2015 ((4407, 398 -0153 Fkoridallotary8eMvbe.com . h**sk*ds*skds+ k*+ k+ k*+ k+ k****d: *sksN*+ k# ****ik+ k+ k*d: dN*****ik*sksk*sk*ak*ak. k*gs**ik*********H +*ek*+k*** *** :s z *sk************* ********* APPROVED BY /L 7` G / Plans Examiner 3//71f Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) 1 Planning and Zoning Criteria Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax: (305)756 -8972 Folio Number:112231O15O18O Owner's Name: TROY & JUDITH ALWINE Job Address: 471 103 Street Miami Shores, FL 33138 -2456 Owner's Phone: Total Square Feet: Total Job Valuation: 2050 $ 2,065.00 Contractor(s) SOUTHERN ASPHALT ENGINEERING Phone 305 - 667 -8390 Primary Contractor Yes Planning and Zoning Criteria and Comments Approved: Yes Date Approved: 513112011: Yes Comments: OVERLAY TO EXISTING SITUATION. OP ID: MA .AWRD� CERTIFICATE OF LIABILITY INSURANCE �.� --�'"` DATE(M20 /11YY) 05/20/11 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 policy(ies) 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 305 - 223 -2533 (Sure Insurance Brokers 2700 SW 137 AVE 305- 220 -0765 Miami, FL 33175 Javier A. Fernandez CONTACT NAME: c.No. Ext): (NC, No): ADDRESS: PRODUCER SOUTH -2 CUSTOMER ID #: INSURERS) AFFORDING COVERAGE NAIC # INSURED Southern Asphalt Engineering Inc 7302 SW 42 St Miami, FL 33155 INSURER A : Progressive Inc. Co. OCCUR INSURER B:Colony Insurance Co. INSURER C : 11/21/10 INSURER D : EACH OCCURRENCE INSURER E : X INSURER F : $ 50,000 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 INSURANCE 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MMIDDIYYYY) LIMITS B GENERAL LIAEULRY COMMERCIAL GENERAL LIABILITY X OCCUR GL3655448 -A 11/21/10 11/21/11 EACH OCCURRENCE $ 1,000,000 X DAMAGES (RENTED PREMISES (Ea occurrence) $ 50,000 CLAIMS -MADE MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENII -1 AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY JILT LOC $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 06098475 -3 12/10/10 12110/11 COMBINED SINGLE LIMIT (Ea accident) $ 500, 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ X X $ $ UMBRELLA UAB EXCESS LUU3 OCCUR CLAIMS -MADE EACH OCCURRENCE $ _ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER!EXECUTIVE C`.FFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Y/ N N C A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ I I E.L. DISEASE - EA EMPLOYEE $ below E.L. DISEASE - POLICY LIMIT $ DRIVEWAY,PARKING AREA OR SID HEWALK PAVINNGOR REPAVING Schedule H more space Is required) __-_-.- ._.-. Miami Shores Village Fax: 305 -756 -8972 10050 NE 2 Ave. Miami Shores, FL 33138 VILLAMS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE _ ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Proposal /Contract Customer: Troy Alwine 471 NE 103rd Street Miami Shores, Fl 33138 Southern Asphalt [ngineering Inc. licensed & Insured Dade [981900 Broward 06 -38 -12901 X 7302 S.W. 42 Street Miami, fI.33155 305 - 667 -8390 / 305 - 667 -0396 www .soufhernasphalfengineering.com Date 5/7/2011 Proposal # 293188 Job Name: 471 NE 103rd Street Miami Shore Email: troycalwine @gmail.com Phone # 305 962.8749 Fax # 305 530.0605 We hereby submit specifications to furnish labor matrial & equipment for the following work as requested: Troy, This proposal is for the overlay of your half of the driveway which leads to the back of the home, the entire driveway behind the home and the entire approach in front of the home. Work to be performed in 1 mobilization. 1- Saw Cut, Removal & Disposal of a 2' perimeter around drain inlets, manhole covers and abutting edges to doors, sidewalks, walkways, etc. 2- Clean entire existing asphalt area to be overlayed using power air blowers and manual push brooms. 3- Application of RC-70 Tack Coat to promote adhesion between prepared surface and preceding asphalt surface. 4- Filling in and rolling of low lying asphalt areas prior to asphalt overlay. 5- Pave prepared areas using asphalt plant hot mix (S -111) at +/- 1-1/2" thickness. 6- Rolling and compaction of spread asphalt using a 4 -5 ton vibratory roller. Permits (If Required) Permit Processing Fees & any incidental work to such permit will be billed separately. Payment to be made as follows: 100% Upon completion All materials guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications Involving extra costs will be executed only upon written orders, and will become an extra charge over and above the proposal. All agreements contingent upon strikes, accidents or delays beyond our control. Respectfully submitted, Southem Asphalt Engineering Inc. Total $2,665.00 Steven Zabielinsky Note: This proposal may be withdrawn by us if not accepted within 30 days. ACCEPTANCE OF PROPOSAL -The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance 1 g t 20k 1 Print Name CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/20/2011 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 policy(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 A&A Underwriters, Inc. 8796 SW 8 St Miami, Fl 33174 CONTACT Pablo M Conde larDO.NI, . ), 305 - 220 -7447 (FAI , No): 305- 2204821 smut. moass- pmc @aaunderwriters.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Bridgefield Employers Insurance co. LIABILITY COMMERCIAL GENERAL LIABILITY INSURED Southem Asphalt Engineering 7302 S.W. 42nd Street? Miami ST 33155 -4508 INSURER B : INSURER C: INSURER D : $ INSURER E : $ INSURERF: CERTIFIC 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 INSURANCE 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 LTR TYPE OF INSURANCE ADOL ,INS SUBR VD POLICY NUMBER POLICY EFF (MM/DDlYYYY) POLICY EXP (MM/DDIYYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ CLAMS-MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENII GENERAL AGGREGATE $ AGGREGATE POLICY LIMIT APPLIES ..IIFCOT PER: LOC PRODUCTS - COMP /OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OVVNED HIRED SCHEDULED NON -OWNED AUTOS COMBINED SI GLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLALIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTON$ $ A WORKERS COMPENSATION AND EMPLOYERS' UABIUTY y/ N 4NYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? WC (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /A 830 -43843 12/28/10 12/28/11 WC STATU- OTH- TORY LIMITS ER E.L EACH ACCIDENT $ 1,000,000 E.L DISEASE - EA EMPLOYEE $ 1,000,000 E.L DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER 1 Village of Miami Shores 1050 N.E. 2nd Avenue Miami Shores, Florida, 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD PDF created with pdfFactory Pro trial version www.pdffactory.com Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 REQUIREMENTS FOR DRIVEWAYS, WALKWAYS & PATIOS Permit application must be accompanied by: ❑ 2 Copies of survey (no more than 7 years). ❑ Surveys shall be reviewed and approved by HRS department. ❑ If survey is older than 7 years it needs Survey Affidavit. ❑ Show on the 2 copies of the survey location and size where the work will be done. ❑ If owner is doing the job, owner must fill and notarize Owner Builders Disclosure form (This form must be signed and notarized in the building department only). ❑ On survey show details of labor: measures, scope of work, material to be used & depth of foundation. ❑ If swale is involved in the project, a right of way affidavit must be signed and notarized by home owner at Village Hall. •• ••• • • • .• • •• • •• • • • •'• • • • •• • • • • • • • •• •d• •• • • • •• ••• ••• • ••• • • • • • • • • • • J • • • • • • • • • • • •• • • •• • • 00 •• • • • • • • • • ••• • ••• • ••• • • • • ••■ • • • • • • • • • • • • • ••• • • • • • • • • • • • • • • •• •• • • • •• •• ••• • • • ••• • • SAE Southern Asphalt Engineering 7302 SW 42nd Street, 21"1 Floor Miami, FI 33155 Tel: 305 667.8390 Fax: 305 667.0396 Proposal Date 05/07/2011 Estimate No. 293188 TO Troy Alwine 471 NE 103rd Street Miami Shores, Fl 33138 Phone No. 305 962.8749 Fax No. 305 530.0605 lob Site Location 471 NE 103rd Street We hereby submit the following specifications and estimates for Troy: This proposal is for the asphalt overlaying of the driveway and rear parking area to your property located at; 471 NE 103rd Street. Driveway will start from the inside edge of the public sidewalk to the rear of the home. 1- Saw cut a 1' perimeter around all edges to sidewalk, walkways, etc. in areas to be overlaid. 2- Clean surface to be overlaid with push brooms and power blowers. 3- Application of RC /70 tack coat to promote adhesion between existing asphalt base and new hot asphalt overlay. 4- Pave prepared surface using asphalt hot mix (S -111) at +/- 1.5" thickness. 5- Fill in and rolling of low lying areas. 6- Rolling and compaction of spread asphalt using a 4 - 5 ton roller. Warranty - Material and workmanship guaranteed for 1 -year, excluding normal wear and tear. Permits and incidental work to such permit will be billed separately. We propose to furnish material and labor in accordance with the above specifications for the sum of: Payment to be made as follows: 100% upon completion. All materials guaranteed to be as specified above. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from the above specifica- tions involving extra costs will be executed only upon written orders, and will become an extra charge over and above the original estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Total $2,065.00 Authorized Signature ACCEPTANCE OF PROPOSAL - The price above, specifications Date of Acceptance and conditions are satisfactory and conditions are hereby accepted. You are granted authorization to perform above work as specified. Payment will be made as outlined above. Signature SAE Southern Asphalt Engineering 7302 SW 42nd Street, 2nd Floor Miami, F133155 Tel: 305 667.8390 Fax: 305 667.0396 Proposal Date 05/07/2011 Estimate No. 293188 TO: Troy Alwine 471 NE 103rd Street Miami Shores, Fl 33138 Phone No. 305 9624749 Fax No. 305 530.0605 Job Site Location 471 NE 103rd Street We hereby submit the following specifications and estimates for Troy: This proposal is for the asphalt overlaying of the driveway and rear parking area to your property located at; 471 NE 103rd Street. Driveway will start from the inside edge of the public sidewalk to the rear of the home. 1- Saw cut a 1' perimeter around all edges to sidewalk, walkways, etc. in areas to be overlaid. 2- Clean surface to be overlaid with push brooms and power blowers. 3- Application of RC /70 tack coat to promote adhesion between existing asphalt base and new hot asphalt overlay. 4- Pave prepared surface using asphalt hot mix (S -111) at +/- 1.5" thickness. 5- Fill in and rolling of low lying areas. 6- Rolling and compaction of spread asphalt using a 4 - 5 ton roller. Warranty - Material and workmanship guaranteed for 1 -year, excluding normal wear and tear. Permits and incidental work to such permit will be billed separately. We propose to furnish material and labor in accordance with the above specifications for the sum of: Payment to be made as follows: 100% upon completion. All materials guaranteed to be as specified above. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from the above specifica- tions involving extra costs will be executed only upon written orders, and will become an extra charge over and above the original estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Total $2,065.00 Authorized Signature ACCEPTANCE OF PROPOSAL - The price above, specifications Date of Acceptance and conditions are satisfactory and conditions are hereby accepted. You are granted authorization to perform above work as specified. Payment will be made as outlined above. Signature Miami Shores Village APPROVED-- MG DEPT • , • - • . • - ' BID sualEct t STATE AND ()if 112" —N15 NANCE WITH AU:FEDERAL :wmiOEs AND REGULATIONS F.I.P 0.3875VCR ON PL 4' C.B.W. 0.39' CL ONPL RIP in* NO CAP • '.0"coito_eimi.%-**'. 20' PWY • • • • • • • • • • BC F.I.P 112` 1/2* NO CAP NO CAP .:.1511.00"1\f?" •.=. • .. **Ar-kl•`. •" • • • • • • • 04 • • • • • SURVEYOR'S • NOTE: • • • • •• • • • • • • • • • • • •• •• - 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. LiADCADItivAilteerestdat MIMS 13&4912114 EST 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 471 NE 103 Street Miami Shores, FL 33138 -2456 1122310150180 Block: Lot: TROY & JUDITH ALWINE Owner information Address 471 NE 103 Street MIAMI SHORES FL 33138 -2456 Phone Cell Contractor(s) Phone SOUTHERN ASPHALT ENGINEERING 305 -667 -8390 CeII Phone Approved: Yes Comments: OVERLAY TO EXISTING SITUATION. Date Approved: 5/31/2011 : Yes Date Denied: Type of Work: DRIVEWAY OVERLAY Bond Retum : Scanning: 3 Additional Info: ASPHALT Classification: Residential Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.80 $3.00 $3.00 $0.60 $200.00 $9.00 $2.40 $219.80 Pay Date Pay Type Invoice # DS -5-11 -41056 06/16/2011 Check #: 1172 05/26/2011 Check #: 1033 Amt Paid Amt Due $ 169.80 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final Foundation 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. June 16, 2011 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date June 16, 2011 1