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EL-12-1899Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 202010 Scheduled Inspection Date: February 18, 2014 Inspector: Devaney, Michael Owner: GROS -JEAN, THERESE Job Address: 10306 N MIAMI Avenue Miami Shores, FL Project: <NONE> Permit Number: EL -10 -12 -1899 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360131010 Contractor: MONTEGO ELECTRIC COMPANY INC Phone: (561)385 -0629 Building Department Comments RE WIRING REAR HOUSE SERVICE INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP- 194006. CREATED AS REINSPECTION FOR INSP - 193847. CREATED AS REINSPECTION FOR INSP- 17977$. Canceled by contractor. 24 oct. 2013. Failed Not ready. Correction Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. February 14, 2014 For Inspections please call: (305)762.4949 Page 6 of 30 Marie T. Gros -Jean 10306 N. Miami Ave Miami Sept VIA CERTIFIED AWL & RECEIPT Michaud Electric 3882 N.W. 207" Road Miami, FL 33055 Re: Permit # EL -10 -12 -1899 Expiration Date: 09/30/2013 Dear Michaud Electric: I, Marie T. Gros -Jean, property owner notifying Michaud Electric's services are hereb- a result of poor performance. Please be advised that your company is property. Sincerely, 04 QCP.vt. (// Marie T. Gras -Jean STATE OF FLORIDA; COUNTY OF MIAMI -DADE Sworn to and subscribed before me this /fo' d [ J Personally known to me; or [X1 Produced Ide �� 1' A cc: Miami Shores Building Department a s ;r�B I ' Lo WM• I- `i ELoo� .Z Mme, �av=irm X CLX 4 � ¢ v CMf MII O o Q � a, woo � >M E-H G O Ln O M ru a r` 0 cx ,n o r, 3w �N 00 . M Ind ;r�B a, woo al V)WLL .01-40 Z U 811 }® 7 Y�VA. w J 1yo M °1` ru M -- rq O C3 '------- Ln M M ru rq r%- 40 AN .1 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 Permit Type: Electrical OWNER: Name (Fee Simple Tideholder):171 t 0s2 Permit No. Master Permit NoZY 2— r r e Phone# (Q6�! q,9- W Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: AP 30L A IA 0 = _946 City: Miami Shores County: Miami Dade Zip: Folio/Parcelt 1121 Z60 /?z 16 /0 Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: (4 A) C-16-0 ` (� C�� Phone #: Address: 41,2 7,2, e�,17c7o toe-c—oi City: Qualifie State Q Contact DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: DAddress Description of Work: ONew ORepair/Replace ODemolition Submittal Fee $ Permit Fee $ S, ®G' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond Technology Fee $ TOTAL FEE NOW DUE $ Ze 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 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. c � Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of O(_, 2013 , by rn"J a (91—') S' °-Z' day of , 20 _, by , who is personally known to me or who has produced � t 6D who is personally known to me or who has produced As identificatio W11614%�take an oath. NOTARY PUBLIC • �o7d' �`'% Sign: Print: My C _ ell APPROVED BY 7" G� /Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: Zoning Clerk Miami shores Village OCT 17 2013 Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. Q pees Name {pv mple Title Holder)` Phone # 2-01 City: -A/1 LO -OWL State: jLc' Zip Code: Job Address (of where work is ring done): 15e4K -F AS ,e, City: Miami Shores State:_Flodda Zip Code: Contractor's Coma Address: City: Qualifier's Name: Architect/ Engineer of Record Name: State: 1----f Zip Code :3�'6 Lic. Number: Phone #: Address: City: State: Zip Code: Describe Work: F/' t S �, O A V– C� F�1@ I hereby certify that the work has been abandoned and/or the contractor /architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless for all legal involvement. Signature - Signature gwheiorAgeni "CcgtreororArohite The foregoing instrument was aknowledged before me The foregoing Instrument was aknowledged before me thi�l,,L day of ,2Q6r,bY this *-- day of 4C n 2Cj5by �O Who is personally known to me or who has produced who is personally known to me or who has produced as Indentific aUon. as Indentific ation. Marie T. Gros-Jean 10306 N. Miami Ave Miami Shores, Fl, 33150 September 16, 2013 VIA CERTIFIED MAIL & RECEIPT Michaud Electric 3882 N.W. 207x` Road Miami, FL 33055 Re: Permit # EL -10-12-1899 Expiration Date: 09/3012013 Dear Michaud Electric: 1, Marie T. Gros-Jean, property owner of 10306 N. Miami Ave., Miami Shores, Fl, 33150, am notifying Michaud Electric's services are hereby terminated from the above-referenced permit number as a result of poor performance. Please be advised that your company is no longer authorized to enter into the afore-mentioned property. Sincerely, Marie T. Gros-Jean STATE OF FLORIDA; COUNTY OF MIAMI-DADS �:� _CO2 tA C2 Sworn to and subscribed before me this *y of Ir Personally known to me; or Produced Identffica .0 ru Postage $ M Certffled Fee Postmark F-1 C3 Return Receipt Fee Here Signature of Notary Public C3 (End orsement Required) C3 Roweled Delivery Fee (Endorsement Required) cc: Miami Shores Building Department C3 C3 Ln Total Postage & Fees 1 $ $3.56 09/16/2013 M ,59nr 15 ru-------------------------------------------------------- ----------- C3 or po Box No. ---------------- Ciry, State, D- --------------------------------- ANNE M. GANNON _..._.. ... _ ........ ....___.._.__ ..___._._._..__._._.....__..... CONSTITUTIONAL TAX COLLECTOR Serving Palm Beach County Serving you. P.O. Box 3353, West Palm Beach, FL 33402 -3353 *"LOCATED AT** www.pb&ax.com Tel: (561) 355 -2264 4223 GEORGIA AVE WEST PALM BEACH, FL 33405 TYPE OF BUSINESS OWNER CERTIFICATION # I RECEIPT #/DATE PAID AMT PAID BILL # 23-0169 ELECTRICAL CONTRACTOR BEDWARD MICHAEL R EC13002904 I U13.781011- 09!30/13 $27.50 640128328 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2013/2014 LOCAL BUSINESS TAX RECEIPT MONTEGO ELECTRIC COMPANY INC LBTR Number: 200019466 MONTEGO ELECTRIC COMPANY INC EXPIRES: SEPTEMBER 30, 2014 4223 GEORGIA AVE WEST PALM BEACH, FL 33405 -2519 This receipt grants the privilege of engaging in or managing any business profession or occupation within its Jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. _ ANNE M. G AN N O N P.O. Box 3353, West Palm Beach, FL 33402 -3353 **LOCATED AT** CONSTITUTIONAL TAX COLLECTOR www.pbctax.com Tel: (561) 355 -2264 Serving Palm Beach County 4223 GEORGIA AVE Serving you. WEST PALM BEACH, FL 33405 TYPE OF BUSINESS OWNER CERTIFICATION # RECEIPT #/DATE PAID AMT PAID BILL # 23.0106 CW ELECTRICAL CONTRACTOR SEDWARD MICHAEL R EC130t12904 U13.781011- 09/30/13 $264.60 840126329 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2013/2014 LOCAL BUSINESS TAX RECEIPT MONTEGO ELECTRIC COMPANY INC LBTR Number. 200010464 MONTEGO ELECTRIC COMPANY INC EXPIRES: SEPTEMBER 30, 2014 4223 GEORGIA AVE WEST PALM BEACH, FL 33405 -2519 This receipt grants the privilege of engaging in or managing any business profession or occupation within its Jurisdiction and MUST be conspicuously displayed at the place of business and in such a _ manner as to be open.to the view of the public. CITY OF WEST PALM BEACH 2013 to 2014 BUSINESS RECEIPT BUS. TAX ID. CATEGORY DESCRIPTION 16515 238210 ELECTRICAL CONTRACTOR NOT TRANSFERABLE CITY OF WEST PALM BEACH P.O. BOX 3147, WEST PALM BEACH, FL 3341 EXPIRES SEPTEMBER 30, 2014 DBPR - BEDWARD, MICHAEL R; Doing Business As: MONTEGO ELECTRIC COM... Page 1 of 1 9.38.29 AM 1011712013 LIC @115@@ Details Licensee Information Name: BEDWARD, MICHAEL R (Primary Name) MONTEGO ELECTRIC COMPANY INC (SBA Name) Main Address: 4223 GEORGIA AVENUE WEST PALM BEACH Florida 33405 County: PALM BEACH License Mailing: LicenseLocation: 4223 GEORGIA AVE WEST PALM BEACH FL 33405 County: PALM BEACH License Information License Type: Rank: License Number: Status: Licensure Date: Expires: Certified Electrical Contractor Cert Electrical EC13002904 Current,Active 06/24/2005 08/31/2014 Special Qualifications Qualification Effective r ..II . l is 1940 North Monroe Street. Tallahassee FL 32399 :: Email: Customer Contact Center :: Customer Contact Center: 850.487.1395 The State of Florida is an WEED employer. Copyright 2007-2010 State of Florida. Privacy Statement Under Florida law, email addresses are public records. If you do not want your email address released in response to a public - records request, do not send electronic mail to this entity. Instead, contact the office by phone or by traditional mail. If you have any questions, please contact 850.487.1395. "Pursuant to Section 455.275(1), Florida Statutes, effective October 1, 2012, licensees licensed under Chapter 455, F.S. must provide the Department with an email address if they have one. The emaiis provided may be used for official communication with the licensee. However email addresses are public record. If you do not wish to supply a personal address, please provide the Department with an email address which can be made available to the public. Please see our Chapter 455 page to determine if you are affected by this change. https:// www. myfloridalicense .com/LicenseDetail. asp ?SID= &id= B90BB9E6CF35DO816... 10/17/2013 OCT -17 -2013 10:42 Mayes Ins Group 5614910840 P.001 /001 CERTIFICATE OF LIABILITY INSURANCE DATE (ANUDD/YYYY) . 10/17/13 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. E the cettifkate holder Is an ADDITIONAL INSURED, the poles) must be endorsed. U SUBROGATION IS WAIVED, subject to the tetras and conditions of the policy, certain policies may require an endorsement. A statement on this eertNicate does not confer rights to the ceAificate holder in Neu of such endomement(s). PRODUCER Mayes Insurance Group 12 313 45th Street, A 1 West Palm Beach, FL 33407 Phone 1 848 -7110 Fax 561 84046W NAME: Thomas Mayes PHONE 1 84S -7110 F 561 840 -9650 " Imayes8mayesinsurancegroup.com INSUR-M-41 AFFORDING COVERAGE NAICS INSURER A : Travelers Y INSURED Montego Electric Company, Inc. 4223 Georgia Ave West Palm Beach, FL 33405 i INSURER 13 • Phoerlbc Insurance Co 11/25/2012 INSURER C • EACH OCCURRENCE INSURER 0: D TO RENTED MED EXP emon INSURER E: $ 5,000.00 INSURER F: S 1,000,000.00 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, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. �g�EXCLUSIONS I(.TR TYPE OF INSURANCE ADDLSUBA POLICY NUMBER MM1DD/1 YMF AMLOMM I LIMITS A GENERAL LIABILITY © COMMERc AL GENERAL LIAe LnY ❑ ❑ CLAMMADE ®OCCUR ❑ ❑ GEWL ❑ POLICY TEUMrr ❑ APPLIES E P RO• Y 1 -60 6-1 B560643- TIL -12 11/25/2012 11/25/2013 EACH OCCURRENCE s 1,000 000.00 D TO RENTED MED EXP emon $ 100,000.00 $ 5,000.00 PERSONAL BADVINJURY S 1,000,000.00 GENERAL AGGREGATE S 2,000,000.00 PODUCTS - COMP/OP AGG 2,000,000.00 $ B AVRIMOBILELWBIUTY ❑ ANY AUTO ❑ ALL OWNED SCHEDULED AUTOS ® AUTOS ❑ H Ass ❑ AUUTOS E° BA-8A800632- 12 -SEL 11/26/2012 11 /2x/2013 COMN®9NQ LIMB 100,000.OD BODILY INJURY 02er person] $ BODILY INJURY Per awider l S $ ❑ UMBRELLA LIAR ❑ OCCUR ❑ EXCESS LIAO ❑ CLANS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS UAWLITY YIN ANY PROPRIETORIPARTNERID(EC tMVE O�MBER EXCLUDED? (Mandatory in NH) under if 1 d�aibe TI DE�WPTION OF OPERATIONS below N!A WC STATU O . EL EACH ACCDEJT $ EL DISEASE - EA EMPLOYE S E.L. DISEASE - POUCY UMIT $ DESCRIPTDN OF OPERATIONS I LOCATIONS f VEHICLES (Attach ACORD 101, AdditlOnat Remarks Schedule, K more epewl N r�iutred) Electrical Contractor Miami Shores %Allege 10050 NE 2nd Ave Miami, FL 33138 Fwc 305- 75648972 ACORD 26 (2010106) QF k VIYYV •-• . 4I HAM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. V lass -2010 ACORD CORPORATION. An rights reserved. The ACORD name and logo are registered marks of ACORD TOTAL P.001 m -+r IErr- ATWATCR STATE OF FLORIDA :IiIERPINANCiALOFFICIA' DEPAF4TNIENT OF FINANCI^L SEF.LViCE;3 DIVISION *OF MAKERS' COMPENSATION URTIFIC,ATS OF 11LICTION Td BE EXEMPT MOM Fit RIDA WORKERS' :ONSTRUCTI4N WDUSTRY EXEMPTION ' ThiS certifies that the EFFECTIVE DAT5- 02-21-2012 COI WINSATION LAW x• individual listed below has elaoted to be exempt from. Florida W&kers' Compansation law, Wio/2012 PERSON: BEDWAiRD FEW; 650574949 SUS1'NE'S S NAME AND ADORESS: p,11SNT600 ELSOMC COMPANY ' YNC 4220 490MiIA AVE WOST PALM BEACH F4 33405.2598 SCOPES OF BUSINESS OR.TRADE: i- ELECTRZCAL CONTRACTOR EXPIRATION DA'I`S: 0210912014 MICHAEL R IMPORr4PITt Pursew to Poplar 420 . OS(14i, 'F.li., 'an olficar of 0 Corporation why slacts evewptioo tram this ehaptar by (Wing a aortifidato Of CIR<tien adder this section may net rotavvr bcdefits or eomnpnaatian dador this Chapter. Pursuant to Chapter 440,I)NIM. F -6-, t41110nataC of 6JOCt14a to be axampt— Mly 0p1Y witltln tfia Scapa of The busfncu or wade 115,04 an the netted of •ataatl44 to he enampL Pursuant to Cpapter,440.05410f, r•.it., Not1495 et •dieatTda to bd asamin lad 40119atas at CToailon m be oaampt shall Da aapjoei to revoeation tf. it arty tlrne after the flilnfl: of the eahea or •cpe Issuanee of the, eertificato, ,hd parson aeetod on tfrn oetita or caruilieate no tandar meets 'Me Mquirament5 of iAia i9e,I41; for fasaonee of a aertificata. ?Ate dationment 9ba(1 revoke it certnleata ct any Gina. far failure df the person osmed an the coll.14dra m meet cbo raqu061114493 of thfe secttnrt. QUESTIONS? (850) 413 -181 vC-Z5Z CERTIFICATE OF HLECTiON TO SE .EXSM"' REVISED-0.1-11 PLEASE CUT dUT TK:E CARD• BEI,'OW A-ND RETAIN FOR PUTU•RE ROPERANCE STATE: OF FLORIDA DEPARTMENT OF VINANCIAL SERVI01:S IMPORTANT F pgrsuisnt; to Chapter 440.0604); F.S., an officer of a oorperttion who mvisiON OF•WORKIFts, COMPINSATICN CONSTRUCTICK ZNrlua AY FLORIDA ' 0 Closets otltftnptien from tills .ghapS ®r`'by Elting b certlEtcatls of election ` under this section not recdver baIiiihs or compensation undtir thig dER�0TEOF MAOTiON TO p6lsj@<:fYfPT FROM � WOAKRA& COMPENSATION LAW .mqf D' chaptsr. -EFFECTIVE: 02• /io /2012 EXPIRATUN iaAT9: 0.R/09/2014 9ursupm to Chapter 440.0600, F.S., Cortificates of election to be H MICHAq.L R PERSON: MICifAEL R $EDWARD exempt... apply oniv within the scope of the business or. trade Iinod on R the notice of election to be ,exempt FEli4: SUSINF-SS NAME AM ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notions of W041ion to be exempt and aartificalas of- e14C11tTn to he exempt ,,hail be subieat to revocation moNFBGo %LECTRi: 00ANY INC if. at any, -time after the filing of the notice or the Issuance of the aaso osorettw AMP wflS; pa:H aEaGw, FL 334o5•xsta cert2ficate, the person namod on the notice or cereificote no longer meal the requirements of this section for issuance of a ceHfiee:e, The depar:tMetix Shall revoke a certificate at any time for failure of the pertdn named if the aertifiCata to meet the requirements of 1418 SCOpl: OF 9USI,ESS 4R TRADE Setition. 1• ELgCTR,CAL CONTRACTOR allESTIONS? (8501 4 13 -11308 CUt MERE Corry botiom Pof'tiort on the job, keep upper portion for your records. LDOILOOd m��Z�LO E�O� El ��0 Miami Shores Village OCT 1 i Ziiv2 tl. Buildin g Department artment 10050 N.E.2nd Avenue, Miami Shores, Florida 33138, Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BU D G Permit No. PERMIT APPLICATION master Permit No. FBC 2010 Permit Type: Electrical Z OWNER: Name (Fee Simple Titleholder): A ti �� ker -eSc- 6,'OZ �&o,,Phone#: �Z K- Email: JOB ADDRESS: IO10 J) RL City: .Miami Shores County: Miami Dade Zip: X222, K-0 Folio/Parcel#: /1 - / 2) 1i' 08 - 10 l � Is the Building Historically Designated: Yes CONTRACTOR: Company Narr Address:3T92 ITV,\ 2�P7 NO Flood Zone: City:m(�_%Ki State: Zip: 1?, 0 sc - QualifierName:'le — _%S!4 t-t Phone#:17C -223^ /2 %O State Certification or Registration #: f l 3 O l 2 ? C7 -3 Certificate of Competency #: O 360 O 0 J?a Contact Phone#: jj%'27 3 - 127 b Email Address: DESIGNER: Architect/Engineer: �r Value of Work for this Permit: $ WO Square/Linear Footage of Work: Type of Work: OAddress . Description of Work: ONew — ZRepair/Replace ODemolition Submittal Fee $ Permit #6e $%3 ®f ®0 CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ 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 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 VOPROVEMENTS 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. r . � Signature,., Signature Owner or Agent V Contractor The foregoing instrument was acknowledged before me this % The foregoing instrument was acknowledged before me this C) day of 41:TOQER , 20 L2-, by MARIE 7R' ERME Mtos -TEAy day of 1 0 , 20 lZ ; by 01AA,LA1tSZ who is personally known to me or who has produced STATE who is personally known to me or who has produced - rhm-r/ FF cAm ea/ As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: OS EP J Print: Zyw My Commission Ex ' �`ra�6 JOSEPH L. ANDRE My Commission Expires: MY COMMISSION * DD910821 _.. p 1:xPIRM. Sept - 6,2013 (40� 388 0193 Fio "Nol" "VIO =" -� ,"t' '�.,i ,1EAN o. ' kaRnkak�kaRakB� :kakdasFs��k�kskak sk sk�k�Rakakakakskd�sk�kHsakakaknk�kiksk�Rxak�kdadsakHasksks kskHa$ asksksksksksksk�Ia$a8cgakak�kXa sk $ isk�>�f8�ak��RSk�kdsgwksksksRSk amded ytn NoWYY Unde"o APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)