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MC-12-1373Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 182383 Permit Number: MC -7 -12 -1373 Scheduled Inspection Date: December 05, 2012 Inspector: Perez, JanPierre Owner: SALYER, THOMAS Job Address: 311 NE 94 Street Miami Shores, FL 33138- Project: <NONE> Contractor: ENGINEERED AIR LLC Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1132060136100 Phone: (954)974 -7277 Building Department Comments EXACT NC REPLACEMENT ANED CHANGE DUCT WORK Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 177306. CREATED AS REINSPECTION FOR INSP- 177048. CREATED AS REINSPECTION FOR INSP- 176238. NEED TO SEAL THE FLEX COLLARS FROM THE INSIDE. JPP 8/6/12 work not done ductwork still sweating jpp 1 '2,,// December 04, 2012 For Inspections please call: (305)762 -4949 Page 25 of 37 Miami Shores Village AMCMTLEJ,11 JUL 2 2612 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 B CJII,DG PERMIT APPLICATION Permit Type: MECHANICAL JOB ADDRESS: , WE- 1('IT c City: Miami Shores County: Folio/Parcel #: Q 1 �J�l`i� — 01-3 -GI C' Is the Building Historically Designated: Yes NO FBC 20 Permit No. Master Permit No. A 2.— )313 Miami Dade Zip: Flood Zone: OWNER: Name (Fee 'Simple Titleholder): —Cho 0. ►4S 4 1.4 At LIa 1� )J SAL \-I `i . Phone#: 38 - a (9.7 i Address: flfl '311 10 9 Lk t� ST City: Y`°1i P}vAl Hu'2rS State: I` 1- Zip: -5`s 1. Tenant/Lessee Name: Phone #: Email: CONTRACTOR: Company Name: 0 C 1 � rP- 5 D 41 1'Z LL \ Phone#: g� tt 5 7 T Y 7% Address: O `5 � N �'� �R 1=ws �� r x State: �. Zip: 31 O(. City: 01,4 4 ►��' Fa lac H Qualifier Name: D 'N.., r F State Certification or Registration #: C �� s Sb 0 Contact Phone #: 1 59 q 1 DESIGNER: Architect/Engineer: Phone#: Sb 1 `7,32 &i cIo 1. Certificate of Competency #: %`77 Email Address: Gjrf��'C ewC�►we�cr�ctr Phone#: Value of Work for this Permit: $ ` to SO Square/Linear Footage of Work: on ONew EiRepair/Replace ptioldiOf,Wotk:, n;q 1;* Demolition *+ x******* ** a: *+ x*+x***** *** ****ws:+x**+ ***,$ ee r******** �ax��x�:s::x** **+xa��x **** *** *x * ** **** ** Submittal Fee $ Permit Fee $ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 1\ LC) 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 A}'H'IDAVIT: 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 or Agent The foregoing instrument was acknowledged before me this G c day of �1/4i , 20 i j , by 11LOJV10LS (J) Sag g ex who is personally known to me or who has produced P As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commissi * * * * * * * * ** 50vvvvv, ose "'ee' PATRICIA T. SOMMERS Notary Public - State of Florida �' tgri„o?:d`. My Commission r# EEa180881 2018 s« xgretkin *snRT)lansExaner * ** ***************************** * * * * *** * * * * * * * * * * * ** * * * * * * * * * ** Signature The foregoing instrument was acknowledged before me this day of ao J" v, 20 (I; by . (S A •Tkf who is personally known tame or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commis ?� � � �,* Notary Public - State of Florida j My Comm. Expires Mar 19, 2016 qa�� Commission # EE 180881 APPROVED BY Structural Review Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) 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 �j PERMIT NUMBER: MC /2--) v 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): / / A✓ 4- City: Miami Shores Village County: Miami Dade Zip Code: 33/3 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 ❑ NO ARHI Sheet Attached: YNO ❑ Contract Attached: YES UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER (2a ei -l-e ,y" AHU or PKG. UNIT MODEL # P ),/ /' Pip rh COND. UNIT MODEL # ,n fig 1, 0,90 KW HEAT NOM TONS '-2 ° AHU CU PKG 1) M.C.A AHU CU PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG 3) VOLTS AHU CU PKG PKG UNIT / / PKG UNIT / / EER/SEER YES NO REPLACING DUCTS YES " NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4 °CONCRETE SLAB YES NO - YES NO NEW ROOF STAND YES NOS/ YES NO NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: ✓ 1 11,- Phone: State Certificate or Registration N. g Certificate of Competency N. Signature (Qualifier's signature only) Date: NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO. TAX`FOUO NO. STATE OF FLORIDA: COUNTY OF MIAMI -DADE: THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 1. Legal description of prope and street/address: /r � D/v-O/3-G / /7Z 2. Description of improvement: 11111111111 1111111111111111111111 CFN 2O12RO51787 OR BE: 28199 Ps 4285; (fps) RECORDED 07/24/2012 11 i >• 39 :54 HARVEY RUVIW, CLERK OF COURT MIAMI —DADE COUNTY, FLORIDA LAST F'AGE Space above reserved for use of recording office 3J /, //' 9 / Himi j L)2 , 33/3,x' 3. Owner(s) name and address: Interest in property: Name and address of fee simple titleholder: 4. Contractor's n :i e, address and phone number 5. Surety: (Payment bond required by owner from con ractor, if any) Name, address and phone number: Amount of bond $ B. Lender's name and address: 7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be serve, = =. =_5 *A• ded by STASE �� C4 .•' eat � "��°a�,gy Name, address and phone number: OF FLORIDA, dL�� ,� �� of it,s Section 713.13(1)(a)7., Florida Statutes, 8. In addition to himself, Owners designates the following p 713.13(1)(b), Florida Statutes. Name, address and phone number: ��i cops Notice Ewa) __~. S1t. ", 1'3°.,1:' "J'Ct WITNESS my hand 4 VEY ICU 9. Expiration date of this Notice of Commencement: By (the expiration date is 1 year from the date of recording unless a different date is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. p ov!`;a( Sec�ticy Signature(s) of Own;. •r Owner(s)',11,uthbrized{ cer/Director /Partner /Manager Prepared By %, ': ✓) n . Prepared By Print Name (� °1/— �// Print Name Title/Office STATE OF FLORIDA COUNTY OF MIAMI -DADE The #,oreg y in men eacknowledged before me thjsr - day o dp UA� for Title /Office By Individually, or U as Personally known, or U produced the following type of ident Signature of Notary Public: Print Name: (SEAL) Fret_. s Nntary Public State of Fforf VERIFICATION PURSUANT TO SECTION 92,525. FLORIDA STATUTES Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true, to the best of my knowledge and belief. Signature(s) of Owner(s) or Owner(s)'s /authorized Officer /Director/Partner /Manager who s By 123.01 -52 PAGE 3 3/10 By 7/f glt Jul IM PE Mary PoO i - ilk of Florida *Comm Otpirce awn 27, 2018 Cravalssion / EE 211813 F L 1'1[ I 'YOUR MAXIMUM COMFORT AND EFFiCIENCYIS OUR GOAL' ')t 9- NGINEERED IR,la License # CAC045860 - COMFORT BY DESIGN - Toll Free 866 -883 -9073 Office 954 -449 -1600 Fax 954 - 973 -1883 APPT. DATE: RES. 1 COMM. CUSTOMER NAME TOM SALYER STREET ADDR. 311 NE 94TH Ant ST RGRT MUNICIPALITY MIAMI SHORES SEPARATE BILLING ADDRESS CUSTOMER'S E -MAIL ADDRESS STATE FL ZIP CODE 33138 Engineered Air LLC 2520 N Andrews Ave Ext Pompano Bch, Florida 33064 E- AIRLLC.com ESTIMATE# '1 J q 6 7 PHONE 305- 332 -6979 CELL FAX tom •■tomsal er.com INCLUDED MATERIALS AND CONDITIONS, V Vertical Air Handier Horizontal Air Handler New Metal A/H Stand New AM Platform N Emergency Float Switch _ New Emergency Drain Pan New Refrigerant Lines _ Flush Existing Ref. Line V New Drain Une New Condensate Pump NEW EQUIPMENT OPTIONS SELECT OPTION AND INITIAL S.E.E.R. /EFFICIENCY MANUFACTURER TONNAGE /SIZE CONDENSER MODEL# AIR HANDLER MODEL# PACKAGE UNIT MODEL# HEAT STRIP KW AiR QUALITY PRODUCT Condenser On Ground Condenser On Roof New Concrete Slab New Roof Stand V Hurricane Strap To Code Package Unit On Ground d New Duct System V New Supply Duct(s) New Retum Duct(s) New Retum Grill (s) New Supply Plenum New Retum Plenum _ Package Unit On Roof _ Use Existing Electrical Remove Existing Equipment V System Start Up And Test DUCTWORK /OTHER PROPOSED INVESTMENT -, LESS FPL INSTANT REBATE -> LESS OTHER DISCOUNT -> INVESTMENT AT INSTALLATION - MANUFACTURER' S REBATE - INVESTMENT AFTER REBATE -' NEW EQUIPMENT WARRANTIES COMPRESSOR WARRANTY PARTS WARRANTY - LABOR WARRANTY . TERMS AND OPTIONS Crane Service OPTION # 1 16 CARRIER 2.5 CAI6NA030 FV4CNFOO2TO 8 $4,400.00 $500.00 $3,900.00 New Breaker Electrician Needed V Drop Cloths Used V OPTION # 2 REMOVE AND REPLACE ALL METAL DUCTWORK $3,750.00 1 $3,750.00 Lennox Pure Air Filtration Lennox Healthy Climate 16 Filter Lennox Healthy Climate 10 Filter Smoke Detector Ultra Violet Germicidal Light Programmable Thermostat Caller Edge Thermostat Lennox 'Comfort Thermostat Separate Humidistat V A. ply For Permit And ins.ection OPTION # 3 1 $0.00 1 NET AMT. DUE $ ? a. CO. 00 PAYMT. BALANCE DUE 7.2.00.00 E'/5-0. no 10 10 2 YEARS YEARS YEARS PAYMENT BY: CREDIT CARD PAYMENT BY: CREDIT CARD M C • PAYMENT BY: CREDIT CARD YEARS YEARS YEARS FINANCE FINANCE FINANCE CHECK CHECK CHECK YEARS YEARS YEARS' ALL BALANCES ARE DU E UPON THE COMPLETION OF THE WORK AUTHORIZED AND BEFORE INSPECTION ADDITIONAL CONSIDERATIONS: ELECTRICIAN NEEDED TO REWIRE TO NEW AIR HANDLER LOCATION. HANDYMAN NEEDED TO BUILD AIR HANDLER STAND, CONSTRUCT NEW ATTIC ENTRANCE, SEAL EXISTING DUCT ENTRANCE FROM GARAGE TO HOUSE. Any alteration or deviation from above specified prices Involving extra costs will be executed only upon wrltten orders and will become an extra charge over and above this estimate Acceptance of Proposal: The above prices, speclficatlons and conditions are satisfactory, are hereby accepted and you are authorized to do the work as specified. I have read and understand aILterms and conditons ¢t4his contract and my signature constitutes my complete acceptance of suck terms and conditions. Purchaser Signature Date Engineered Air LLC 'ALL AIR CONDITIONING COMPANIES ARE NOT CREATED EQUAL' Date This combination qualifies 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: 4584315 Date: 7/20/2012 Product: Split System: Air - Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: CA16NA030****A Indoor Unit Model Number: FV4CNFOO2 Manufacturer: CARRIER AIR CONDITIONING Trade /Brand name: 16 SEER PURON AC Manufacturer responsible for the rating of this system combination is CARRIER AIR CONDITIONING 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): EER Rating. (Cooling): SEER Rating (Cooling): 28600 13.20 16.00 * Ratings followed by an asterisk (') 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, warranties or guarantees as to, and assumes no responsibility for, the product(s) listed on this Certificate. AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s), or the unauthorized alteration of data listed on this Certificate. Certified ratings are valid only for models and configurations listed in the directory at www.ahridirectoryorg. TERMS AND CONDITIONS This Certificate and Its contents are proprietary products of AHRI. This Certificate shall 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 into a computer database; or otherwise utilized, in any form or manner or by any means, except for the user's individual, personal and confidential reference. CERTIFICATE VERIFICATION The information for the model cited on this certificate can be verified at www.ahridirectory.org, click on "Verify Certificate" link and enter the AHRI Certified Reference Number and the date on which the certificate was issued, which is listed above, and the Certificate No., which is listed below. ©2012 Air - Conditioning, Heating, and Refrigeration Institute Long Air - Conditioning, Heating, ME am and Refrigeration Institute CERTIFICATE NO.: 129872714903925813 CONDENSING UNIT 48° X 48" X 60" HEIGHT SEE DETAIL " I " SEE DETAIL "I" re' , r ;\--•(4-off--.-v-$,....?-.- --,--w- - .-•?-:.Two ,-v-w-&\,---, „ /. / / / v A.,-,,,,N .4 ,w />r <\,0 .."..._ „..„. /, , , , CONDENSING UNIT EXISTING CONCRETE 5LAB OR FOUNDATION BY OTHER n. 2 "X6 "X 12 GA STEEL GALV. CLIPS -RM CLIP BY RM ENTERPRISES. (4) PER UNIT ATTACHED TO THE CONC. W/ (2)Y" X I %* GALV. LONG TAPCON SCREW * TO THE CONDENSING UNIT USING (3) # 12 X 3/4" GALV. SELF TAPING SCREWS. SEE ENLARGED DETAIL "2" EXISTING CONCRETE SLAB OR FOUNDATION BY OTHER DETAIL "I SCALE: 3/4" = I' -O" 0 00 00 .. 0 0 n. U 2° DETAIL "2" N.T.S. w 0 w a_ U ti to am checked TAPCON mpg LOCATION Deals K. Solana P.E. Si VW StIL-N(F- (Rk;-'stp 11\A t Si01)4,c t` L 3366,4 )\.;11-1 kr/ Dt. c.1" ID? lu I Vb. 0 Er JtiL 2 L. r °1■ BY: - I n Miami Shores Village • APPROVED ZONING DEPT LOG DEPT SUBJECT TO COMPLIANCE WITH ALL FEDERAL STATE AND COI INTY RULES AND REGIJI ATMS Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 MC- 12- 1513 Inspection Number: INSP- 176384 Permit Number: EL -7 -12 -1379 Scheduled Inspection Date: July 26, 2012 Inspector: Devaney, Michael Owner: SALYER, THOMAS Job Address: 311 NE 94 Street Miami Shores, FL 33138- Project: <NONE> Contractor: LONGMAN ELECTRIC INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1132060136100 Phone: (305)758 -1211 Building Department Comments AC HOOKUP Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Commen s�- 70/7 / July 25, 2012 For Inspections please call: (305)762 -4949 Page 23 of 26 Miami Shores Village (ECEUVE Building Department JUL 3 J 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 UVI BU DING PERMIT APPLICATION Permit Type: Electrical __910 JOB ADDRESS: � I) FBC 20 Permit No. E 12-- 3 Master Permit No. TI 2 -1 3 City: Miami Shores County: Miami Dade Zip: . / ?� Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Tiatlehhoolder): —TOM 6 (-T-0(11 Address: ',11 / N 'l-1 ST-- City: v941- 5/ /0 ( State: Zip: Tenant/Lessee Name: Phone #: Email: -7D 'wc -rom Y L a._ r 7 CONTRACTOR: Company Name: L� 6in i't 7--&" 16 6- Phone #: >6.2 '78-8 12-11 Address: Uzili f -. q 6 sr City: Srf O �L— Zip: 6 Qualifier Name: IAA T C 41- Z---c '4 L— Phone #: 3 -75". --_-/..7.4/ State Certification or Registration #: r [.... ). 4.9 ® '713 Certificate of Competency #: Contact Phone #: 3C7 'L I 2-11 Email Address: DESIGNER: Architect/Engineer: .. Phone #: Value of Work for this Permit: $ e g C) " Square/Linear Footage of Work: Type of Work: °Address °Alteration ONew °Repair/Replace °Demolition Description of Work: `C- hiQOG< * * ** sae* 1: * ,, *** **** ****** x********* Fees***** ***** ***** *********** ******** ** * * ** *** Submittal Fee $ �/ Permit Fee $ /s r& "® CCF $ CO /CC $ S : nning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ �� ° I 0 1 •� Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) d v ; f 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 Signature &--7114-(141/ (; C,��✓a –�� Owner or Agent �p The foregoing instrument was acknowledged before me this /7 Contractor The foregoing instrument was acknowledged before me this 02(9--- day of —Y , 201 2—r6y TI—t0114- 5 f , day of , 201,27 by e who is personally known to me or who has produced -1 As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: w'. 511vere res s. who • ers y mown do me or who has produced as identification and who did take an oath. NOTARY PUBLIC: 03196 `16 °• t41 _ Sign: pRy Q�BIIC' _ Print: ommi5 ° I �c My Commission Expire s' . EE11 30 59••:10 \ APPROVED BY 2311-46'7 r Plans Examiner Zoning Structural Review Clerk (Revised 3 /12/2012)(Revised 07/10 /07)(Revised 06/10/2009)(Revised 3/15/09)