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EL-12-1816Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 "E/ 2 -- 1 15 Inspection Number: INSP- 179244 Scheduled Inspection Date: October 15, 2013 Inspector: Devaney, Michael Owner: MORGAN, MARY Job Address: 307 NE 95 Street Miami Shores, FL 33138- Project: <NONE> Contractor: UNIVERSAL ELECTRICAL SERVICES Building Department Comments EL WORK FOR NEW POOL Permit Number: EL -10 -12 -1816 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number (305)606 -2098 Parcel Number 1132060136000 INSPECTOR COMMENTS False Inspector Comments Passed X '1r Failed Correction / Needed l Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Phone: (954)792 -5444 October 11, 2013 For Inspections please call: (305)762 -4949 Page 2 of 25 Miami Shores Village Building Department: 4 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 j Tel: (305) 795.2204 Fag: (305) 756.8972 JAN 1 5 2.011 INSPECTION'S PHONE NUMBER: (305) 762.4949 FBC 20 BUILDING Permit No. L L - I (9-1 PERMIT APPLICATION Master Permit No. p� JLi�l /5 Permit Type: Electrical JOB ADDRESS: 30:2 AJA. `(S --jj-it&T City: Miami Shores County: Miami Dade Zip: �`J / 3 Folio/Parcel #: Z /— Is the Building Historically Designated: Yes NO 0° Flood Zone: OWNER: Name (Fee Simple City: t Vl t' 10 f 2z`M1' eS g` L State: Tenant/Lessee Name: Email: 13 CONTRACTOR: Company Name: ()A)tV =&S4L- TY1lCA�- �FII U Phone #: 7Jaf- 2�0 )"Yyy Address: / S l O N W cc, 5- 'dtl6 '4y C City: Pi.A4� ®'j State: Zip: 33p Qualifier Name: b.6.4 rl tS 'ATJ%.J+- Phone#: e% 6s-'� -9dt Y State Certification or Registration #: 3 Certificate of Competency #: Contact Phone #: Wf- 6S9 -144 Y Email Address: D 4 J lS DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ / /7 (/ i l Square/Linear Footage of Work: Type of Work: ❑Address, lte —tin n ONew ORepairfflleplace ODemolition Description of Work: �/- �(�1��7�//�I�i�'! ev Submittal Fee $ Permit Fee $ ✓�" ®'' ° Scanning Fee $ Radon Fee $ CCF $ CO /CC $ DBPR $ Bond $_ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ L TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State 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 anjV a reinspection fee will be charged. Signature I Y Signature Owner or Agent The foregoing instrument was ackn wl ged before me this day of 0' , 20/3,b y LeP.�1l�°P who is personally known to me or who has produced � l° As identification and who did take a NOTARY PUBLIC: Sign: g� nt: C ' I�f Contractor l l The foregoing instrument was acknowledged beforepe this day of IOq/` by �1/%i® who is p onally known to a or who has produced - oath. oath. s identification and who did take an oath. Plans Examiner Structural Review (Revised 3 /12 /2012)(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Clerk Oct.11. 2013 4:04PM No. 5578 P. 1 115 S.. Andrews Ave., Rm, A -•100, Ft. Lauderdale, FL 33301-1895'— 954- 831 -4000 VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 30, 2014 DBA: UNIVERSAL ELECTRICAL SNRVICES INC Receipt e#;181-2873 L /ALARMS /CONT.F Business Name: Business Type: (ELECTRICAL CONTRACTOR) Owner Name: DENNIS FONTAINE Business Opened:03/31/1999 Business Location: 1540 NW 65 AV9 State /County /Cert/Reg:EC13002093 PLANTATION Exemption Code: Business Phone: 954 -792 -5444 Rooms , ^rorvenailignusmessvn�y ;.i:•••� a•:., Number of Machinaw Professionals Tax Amount Transfer Fee ;,, V.• „•. SF;Fee a, ; ,r.(?QIt ' :� "'v�?�ior` Yea` Collection Cost Total Paid �tn.�:'..:�;a�.,..:�..:r , 0,00 27.00 >,:r.a = :•fi,,'_= .atS;t'xs.•,.:��,ib�' ..•i: ?�!�':'.'��; *r.....Y��' THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT 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 WHEN VALIDATED 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 doe' oes not indicate that the business Is legal or that It is in compliance with State or local laws and regulations. Mailing Address: DENNIS FONTAINE 1540•NW.63 AVE PLANTATION, FL 33313 Receipt #05A -12- 00011792 Paid 07/26/2013 27.00 2013 -2014 : >': UNIVE18 OP ID: DJ A� R° CERTIFICATE OF LIABILITY INSURANCE 0412=00113rn 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 Phone: 305-364-7800 BROWN & BROWN OF FLORIDA INC Fax: 305 - 7144401 14900 NW 79th Court Sulte#200 Miami Lakes, FL 33016 -5869 Ryan Heimbold CONTACT PHONE No No): INSURER(S) AFFORDING COVERAGE NAIL S INSURER A : *Amerisure Insurance Company* 19488 $ 1'000,00 INSURED Universal Electrical INSURER B: *Amerlsure Mutual Insurance Co 23396 Services, Inc 1540 NW 65th Avenue C ` $ 1,000,0 Plantation, FL 33313 INSURER 0: GEML AGGREGATE LIMIT APPLIES PER rl POLICY X PRO LOC INSURER E: $ 2,000,00 INSURER F • AUTOMOBILE LIABILITY X ANY Auro ALLOWNED SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE POLICY NUMBER WDD M (MMMDfYYYYI LIMITS • GENERAL LUUIILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FK OCCUR CPP20713630301 05/01/2013 05/01/2014 EACH OCCURRENCE $ 1'000,00 PREMISES Ea O=Mw ce $ 300,00 MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY $ 1,000,0 GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER rl POLICY X PRO LOC PRODUCTS - COMPIOP AGG $ 2,000,00 $ • AUTOMOBILE LIABILITY X ANY Auro ALLOWNED SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS CA20713520301 05/01/2013 05/01/2014 Ea dent) 110001 BODILY INJURY (Per person) $ BODILY INJURY (Per acddent) $ ROP DAMAGE Per scddent $ $ B X UMBRELLA LUU3 EXCESS LIAB X OCCUR cLaMS MADE CU20713540302 05/01/2013 05/01/2014 EACH OCCURRENCE $ 5,000,00 AGGREGATE REGATE $ 5,000,00 DED I X I RETENTION $ 0 $ • WORKERS COMPENSATION AND EMPLOYERS' EMPLOYERS LIABILITY ANY PROPRIETORIPARTNERlEXECUTIVE YIN OFFlCERMIEMBER EXCLUDED? El (Mandatory In NH) If yYes desaft under DESCRIPTION OF OPERATIONS below NIA C206948103 05/01/2013 05/01/2014 X I WC STATU- E.L. EACH ACCIDENT $ 1,000,00 EL DISEASE - EA EMPLOYEE 1,000,00 EL DISEASE -POLICY LIMIT $ 11000,00 • Equipment Floater $1000 deductible CPP2071353030013 05/01/2013 05/01/2014 Leased/ 100,00 Rented DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addlttonel Remarks Schedule, tt more space Is required) CERTIFICATE HOLDER CANCELLATION MIA -138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 AUTHORMED REPRESENTATIVE ACORD 26 (2010105) ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Jan 15 13 07:31a Stewart J 9549905025 p.5 STATE OF FLORIDA 10 DEPARTMENT OF BUSINESS AND PP.OFESSIONAL REGULATION ELECTRICAL CON'. UCTORS LICENSING BOARD (8 5 0 ) 487-1395 1940 NORTH MONRQE STREET TALLAHASSEE 410. FL 323.99 -0783 FONTAINE., DENNIS UYNOND 'UNI'VERSAL ELECTRICAL SERVICES INC 1540 NN 65 AVENUE PLANTATION F'L 33313 Congratulationsl With this license you become one of the nearly one million Floridians licensed by the Department of Busyness and Professional Regulation, Our professlonals 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.myf`loridalicenso.com. There you can find more information about orir divisions and the regulations that impact you, subscribe to department newsletters and loam more about the Departments 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'congratulatlons on your new license! V��iPM! Lilo ,r.Y• - �?, �ll..5f :a, ¢1 . 40' N '.,65'' rP7�n'T#1,7"�,ON DETACH HERE C:. •` S . T; �' i i': .. i. � . ,�: `fit. f . .. �riicia'l�1iv'�.iic la�tri rIr=2F''1r`R1 QARD 2 2401403 r.{,.11 lip �; ^r `.•its t�ij} ^' ,.. * , ..,;;fit,• :, � -.. +% s fir, =• i Wrs' ' r;s .�CEN.. n d>cc, SECTARY ' "LAYi, Jan 15 13 07:32a Stewart 9549905025 p.6 �-� L — I ` —(R ~ 12 r( UNIVE18 OP ID: JE '"�`. °i CERTIFICATE OF LIABILITY INSURANCE D 01114/20Y3 D1 /1412013 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 INSIURER(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 an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 305. 364 -7800 CONTACT BROWN & BROWN OF FLORIDA INC 14900 NW 79th Court Suite #200 Fax: 305 - 714-'4401 Miami Lakes, FL 33016-5069 PHCNE FAX c EDORE Ryan Heimbold INSURER(S) AFFORDING COVERAGE NAICR INSURER A- *Amerisure Insurance Company! 19488 PERSONAL &ADVINJURY INSURED Universal Electrical Services, Inc 1540 NW 65th Avenue INSURERS 'Amerisure Mutual Insurance Co 23398 INSURERC Is 2,000,00 i GEN'- AGGREGATE LMIT APPLIES P °_R: 71POLICY FX PRO- LO-- I PRO7UCTS- COMPIOPAGG Plantation, FL 33313 INSURER D. $ AUTOMOBILE A X I X i LiABIUTY ANY ALTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS X AUTOS ! INSURER E . 0510112012 iNstiask A I CO eBDINdEDI51NGLE LIMIT 1,000,00 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:_ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 'O 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 D;---SCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIVITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. i SR; TYPEOFINSURANCE AD13LSUBR POUCYNUMBER POLICY POUCYEXP LIMITS GENERAL LIMLITY A X cammERc AL ceNERAL LIABILITY CLAIMS-MADE a OCCUR 10050 Northeast 2nd Avenus CPP2071353010012 05101/2012 05/0112013 EACH OCCURRENCE Is 1 ,OOD,00 1 pREMISES Es oc rerce $ 300,00 ! MED EXP (Any one person ) is 10,00 PERSONAL &ADVINJURY 1 $ 1,000,00 GENR -RAL AGGREGATE Is 2,000,00 i GEN'- AGGREGATE LMIT APPLIES P °_R: 71POLICY FX PRO- LO-- I PRO7UCTS- COMPIOPAGG $ 2,000,00 $ AUTOMOBILE A X I X i LiABIUTY ANY ALTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS X AUTOS ! CA20713620102 0510112012 05/0112013 I CO eBDINdEDI51NGLE LIMIT 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROFERTY DAA9AGE tP.r acrid $ $ X S UMBRELLA LIAR jC EXCESSLIAB OCCUR CLXMS -MADE CU20713540102 05101/2012 05/0112013 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DEO I X I RETENTION s $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY A ! ANY PROPRIETORPARTNEPX- XECL-IVE YIN ' O=FICEFUAEkBER EXCLUDED? (Mandatary In NM ' [fr. . di tse unaer ESCRIPT�N OF OPERATIONS below NIA, C206948102 I 0510112012 I 0510112013 X W C STATU• O_TH- IP R E.L. EACH ACCIDENT $ 11000,00 E.L. DISEASE --=A EMPLOYEd $ 1,000,00 E.L. DISEASE - POLICY -IMIT 15 1.000,00 A Inland Marine ,$1,000 ded i CPP2071353010012 0510112012 05/01/2013 Leasedi 100,00 or Rented DESCRIPTION OF OPERATI;ONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Schedule, ltmare space Is retWlredl _CERTIFICATE HOLDER CANCELLATInN MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 Northeast 2nd Avenus Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE r @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered I marks of ACORD A, P-4w. 311 w v01 !!?W-Ll 9 /Bl-0-01 �� tp,d 9ZO9066i 96 pomels la�C:Lo S� 9 ular Jan 15 13 07:33a Stewart 9549905025 p.7 BROWARD CIOUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301- 1895 — 954 - 831 -4000 VALID OCTOBER 1 r 2012 THROUGH SEPTEMBER 30, 2013 08A: UNIVERSAL ELECTRICAL SERVICES INC RQ��pt�RL9C 'TRICAL /ALARNS /CONTF Business Name: Business Type: (ELECTRICAL CONTRACTOR) Owner Name:DENNis FowrAZNS BusinessOpened:a3 /31/1999 Business Location: 1540 NW 6.5 AVE State /CountyfCerttReg:Ee13o02O93 PLANTATION Exemption Code: Business Ph One: 954- 7q:2;�5 4,- 1i Rooms oyde 7, 1k MdAh1nss Professionals w For Vend lrig euslnate Only Number of AAschlnes: llendittis� 7voe: Tax Amount Transfer Feet q ?N� 'F °r ? = a �&itji ;t ', "stiP'�oP�Yals' a` ColfecUon Cost T otal Pat d 27.00 0. �'�? ? �'• "� :f �T� r� -.h • ,5s .� >' +�: +. r 1.;�: • ��.`i"�0.. ?,, °;':° w. :.+x:^s# R's ,'•� 3161 +: 0. 0 0 27.0 0 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT 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 WHEN VALIDATED 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. Mailing Address: DENNIS FONTAINE 1540 NW 65 AVE PLANTATION, FL 33313 2012 -2013 e b-l40 /8/6 Receipt #30A -11- 00003846 Paid 08/01/2012 27.00 Jan 15 13 07:33a Stewart City of Plantation LOCALi BUSINESS TAX p CERTIFICATE the grass is groates' Valid from Oct 01, 2012 to Sep 30, 2013 Ciassificatlon: 4 -D13 Electrical Contractor 9549905025 p.8 Vertiticate g `i 3 r uz4 Account # OCOS -0387 THIS CERTIFICATE MUST DE CONSPICUOUSLY DISPLAYED Business Name & Address: UNIVERSAL ELECTRICAL SERVICES INC.ID FONTAINE 1540 NW 65 AVE PLAN"T"ATION, FL 33313 C" CLERK VONATURE NOTICE: If Business is sold this Certificate must be transferred within 10 days cr it becomes null and void. L L - /0-/O� - / 9/6� Miami Shores Village M r Building Department C) C1 0 u12 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 + Tel: (305) 795.2204 Fax: (305) 756.8972 BY® ______ >_____ ®mo_ INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No.� PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Address: t73 0 7 Air, City: ®� Tenant/LesseeNPame: Email: Cii rk, I t? i JOB ADDRESS: ) ® 7 &E e V �7 City: Miami Shores County: Miami Dade Zip: q 13 Folio/Parcelk Is the Building Historically Designated: Yes CONTRACTOR: Companv Name: Address: ` City: Qualifier Name NO 4°'" Flood Zone: ckj�_' State Certification or Registration #: C; K UU111 % 144 u--/ Contact Phone #: 7// Email Address: DESIGNER: Architect/Engineer: Value of Work for this Permit: $ goov - ad Type of Work: DAddress Description of Work: _ ONew Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ _ Double Fee $ Structural Review $ le #: � *c — 2711 -zip:�i le#: #: 12 I of Work: CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ ODemolition Bonding Company's Name (if applicable) Bonding Company's Address City State 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature' " Owner or Agent The foregoing instrument was ac w1 ged bef re me this day of �-7 ' 20 a, by /°�� i who is nersonally known to me or who has produced ,T As identification and who did take an oath. NOTARY PUBLIC: Sign: Signature 0" v� Contractor The foregoing in trument was acknowled ed before /me day of 0 10 6& �� 1 d who is p sonally known to a or who has produced As Identification and who did take an oath. NOTARY PUBLIC: Sign: My Commission Expir MY COD/llbftSSl°N # DD961586 ° °° a �- �>�u5510N # DD961386 E}0'IRES: Apnl 19. cola My Co 1 }�E� pu I9, zola 1 -80P N V FI. jYday'1)iS�trtt ANOC. CO. °I�S'g AnaR' Co. sl: sks kakokakaIask :ksksla:k:ksksksiaaksk�a Lr aFrl¢ Keak: kskskskHaaIa: kHaz kskakakHaa•, askrksk�sksksksk: k: kakskakskskskskskalas Iadaalaa8: kxka�azksk= k: ksk: kxkalagasksk: kzksk: k= k$ as kaksknk= kskalsala: kaIask skikakakskHasksksksksksksIasF APPROVED BY �� Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10 12009)(Revised 3/15/09)