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FW-14-1169Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 214212 Permit Number: FW -6 -14 -1169 Scheduled Inspection Date: June 23, 2014 Inspector: Rodriguez, Jorge Owner: PARTON, GAYLON Job Address: 10301 N MIAMI Avenue Miami Shores, FL 33138 - Project: <NONE> Contractor: FIRST FENCE USA INC. Permit Type: Fence/Wall Inspection Type: Final Work Classification: Wire Fence Phone Number Parcel Number 1121360130930 Phone: (305)528 -6940 Building Department Comments REPLACING OLD PERMIT FW 06-858 REPLACE DOUBLE DRIVE GATE 5' TALL CHAIN LINK GALVANI WITH POOL LATCH AND POOL HINGES 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 - 213654. No permit on site June 20, 2014 For Inspections please call: (305)762 -4949 Page 15 of 26 PERMIT #Fa) ,V- 2/69' CONTRACTOR: /,gig/ e (LX i1,ic SUBMITTAL DATE: U °` 5 - ADDRESS: /4'30/ f , ,L29,71, NAME: RESUBMITAL DATES: % df i/ed Pemil Add LJn peel PROJECT TYPE: STRUCTURAL ELECTRICAL ed vr.011° BUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795 -2204 Fax: (305) 756 -8972 INSPECTION LINE PHONE NUMBER: (305) 762 -4949 BUILDING ❑ ELECTRIC ❑ ROOFING ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: cEIVED JUN 0 6 2014 FBC 20 /L Master Permit No. fd ( 1 / U 9 Sub Permit No. ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS /0.3 0/ A), 'Warn; rn; 4/.e City: Miami Shores County: Folio /Parcel #: //0 /3e 0/39930 Occupancy Type: Load: OWNER: Name (Fee Simple Titleholder) Miami Dade Zip: 3 ,91 ..3e? Is the Building Historically Designated: Yes NO Construction Type: Flood Zone: /03i / IV /t'1 A Address: s r /on 170 rfon BFE: Phone#: FFE: City: Warn 5 a j State: FL Zip: 33 hie, Tenant /Lessee Name: Phone#: Email: CONTRACTOR: Company Name: F/ r-$ / `,,Q nee 054 rive a Phone#: Address: 9/ 5O ,, ✓ ' / 6f City: Main i State: Qualifier Name: Bono / a-70 State Certification or Registration #: DESIGNER: Architect /Engineer: Address: Value of Work for this Permit: $ Type of Work: ❑ Ado Descripfjon of Work: A !lar) ? "l v. Sa.28 5'v Pc.- Zip: 3-3/6-5— 06 aw5*diV■Ki Phone#: Certificate of Competency #: Phone#: City: State: Zip: Square /Linear Footage of Work: pie— ISlttie /Go? ❑ New ' Repair /Replace Y Demolition Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ (Revised02/24 /2014) Permit Fee $ CCF $ Radon Fee $ DBPR $ Training/Education Fee $ CO /CC Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ L6 9I.6 0 Bonding: Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City r 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, 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 rei pection fee will be charged. Signature The foregoing OWNER or AGENT strument t\ s acknowledged before me this day of ., on 20 / p , by �D✓1 G F- / ? , who is personally known to Fpp • me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: as CONTRACTOR The foregoing instrument was acknowledged before me this .? day offJfJ , 20 /y , by ,Rr,/?Uef Pine) ne) , who is personally .known to me or who has produced Ps-66W iG `7J lyas identification and who did take an oath. NOTARY PUBLIC: Sign: * *************** * ** * ***** *• APPROVED BY ". Plans Examiner Structural Review (Revised02 /24/2014) * *4*. * *i * * * ** * * * *)R * ** * * * * * * * * ** ire S Zoning Clerk CERTIFICATE OF LIABILITY INSURANCE DATEf3E4/DONYrf) 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 Poticy(tes) 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 doss not confer certificate holder In Ileu of such endorsement(s). right to tho PRODUCER ..i c ACT Excellence Insurance Agency Er (305 2 A Alvarez (305)228 -3800 3801 SW 107 Avenue PH ..1 Miami, FL 33165 • -ES& MalYarezaexcelleneeinsuranoe.net Phone (305)2284900 Fax (305)226.3997 MURMUR DING COVERAGE LURED INSURER A : GRANADA INSURANCE COMPANY ENSURER a : MERCURY INDEMNITY COMPANY OF AMERICA Arcx (305)228 -3997 First Fence USA, Inc 9750 SW 48 ST r"1e01RC = INSURER D : MIAMI FL 33185 INSURER Q; • COVERAGES - -"- CERTIFICATE NUMBER: INSURER F REVION This IS TO CERTIFY THAT THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORnTIIiERPO IC D 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 AU. THE TERMS, EXCLUSIONS AND CONDMONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDIJSUDR LTRR TYPE OF INSURANCE l uau Li e GENERAL LIA91Lny Poi NUb1eER LIMITS ® COMMERCIAL GENERAL LIABfLnY EACH 0• �IRRENCIF g 1,000 000-00 DAMA ❑ ❑ CLAIMBaMADE PREMI�SEETDfl1Eaeccutr q ❑ ® OCCUR Y Y 0185FL00051707rRe>xel $ 100,000.00 08/05/20'13 08/05/2014 'D F� (Any °"e ems) $ 5,000.00 ❑ — ERSONAJ. ADV 1 $ 1,000,000,00 DEN L AGGREGATE LIMIT APPLIES Pak GENERAL AGGREGATE S 2,000,000.00 0 POLICY IZ t M WI Lac PRODUCTS - COMP/OP AGO S 2,000,000.00 AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ AUTO$ OWNED ® AUTOS ❑ HIRED AUTOS ❑ N, ° 61 ❑ uMsRELLA Lori ❑ OCCUR [f Excess LfAe �] CLAIMS -MAD_ ❑ DED ❑ RETENTIONS woman COMPENSATION AND EMPLOYERS' LIABILITY y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE FICERMBER EXCLUDED? ❑ (*amatory In NH) GRIP N ORATIONS be(rsw Y N IA Y BA080000001518 a 08/28/2013 08/28/2014 Fora AliontreLE Li$1IT BODILY INJURY (Per p$ree EXEMPTION FILED a 100,000.00 $ BODILY I INJURY (Per cMen o er aal ,t' D AMAGE Uninsured Motorist EACH OCCURRENCE _ AGGREGATE a s $ 50,000.00 ❑ T TLI ITS ® ERH- $ E.L EACH ACCIDENT $ DESCRIPTION OF OPERATUINB I LOCATIONS / VEHICLES (muter ACORD 101, Addltpnal Ramarirf Schedule, f License # CC 088500663 A more apace Is required) FENCE CONTRACTOR CERTIFICATE HOLDER Miami Shore Village 10050 N.E 2nd Ave Miami Shore, FL 3313$ Fax 305- 756 -8972 CORD 25 (2010 /05) QF ZOOIZOOd CANCELLATION E.L. DISEASE • EA EMPLOYEE E.L DISEASE • POLICY LIMIT, $ S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AU '• + ED R 1988 -2010 ACORD CORPORATION, All rights reserved. T1e4ACORD name and logo are registered marks of ACORD 6E: I. tiLOZ!SOl9O Miami S Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 7952204 Fax: (305) 756.8972 Notice to Owner - Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company merhnbers are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances; Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker compensation iniuries of any person allowed to work under this permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Print Name: Signature: Owner State of Flori County of Miami -Dade ) Sworn tqq and subscribed before me this dayofJu/7 e. ,20 . State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me this day of 3-c-5n, , 20 19 By Ex) r e-1 t '(tb JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Corhlpensation law. 09-18 -2012 EFFECTIVE DATE: PERSON: FEIN: 09/18/2012 EXPIRATION DATE: 09/18/2014 PINO RONOEL 900397344 BUSINESS NAME AND ADDRESS: FIRST FENCE USA INC 9750 SW 48 ST MIAMI FL 33165 SCOPES OF BUSINESS OR TRADE: 1- FENCE ERECTION -METAL * * IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exeMpt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-160E DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 09/18/2012 PERSON: RONOEL PINO FEIN: 900397344 BUSINESS NAME AND ADDRESS: FIRST FENCE USA INC 9750 SW 48 ST MIAMI, FL 33165 EXPIRATION DATE: 09/18/2014 SCOPE OF BUSINESS OR TRADE: 1- FENCE ERECTION -METAL IMPORTANT Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt R E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 Municipal Contractor's Tax Receip Miami —Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY CCNO: 08bs00663 BUSINESS NAME/LOCATION RRST FENCE US6INC 9750 9N48 ST MIAMI, R 33165 OWNER FIRST FENCE USA INC MIAM REMO 000605 RECEIPT NO. NEW BUSINESS 7439559 C i EXPIRES SEPTEMBER 30, 2014 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 TYPE OF BUSINESS WECIA1-TY BUILDING CONTRACTOR For more information, visit www miamidade.govftaxcollector Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 6293526 BUSINESS NAME/LOCATION FIRST FENCE USA INC 9750 SW 48 ST MIAMI FL 33165 OWNER FIRST FENCE USA INC Worker(s) 1 RECEIPT NO. RENEWAL 6559356 PAYMENT RECEIVED BY TAX COLLECTOR 175.00 10/ 17/2013 0228 -14 .000442 LBT EXPIRES SEPTEMBER 30, 2014 Must be displayed at place of business Pursuant to County Code Chapter BA- Art. 9 &10 SEC. TYPE OF BUSINESS 196 SPECIALTY BUILDING CONTRACTOR PAYMENT RECEIVED BY TAX COLLECTOR 086800663 $82.50 10/03/2013 CREDITCARD -14- 000291 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276. For more information, visftmentabmidedgagarigmasiff CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY 08BS00663 FIRST FENCE USA INC D.B.A.: Is certified under the provisions of Chapter 10 of Miami -Dade County Construction Trades Qualifying Board •BUSINESS CERTIFICATE OF COMPETENCY 08BS00663 FIRST FENCE USA INC D.B.A.: P ` • " • NOEL Is certified under the provisions of Chapter 10 of Miami -Dade County QUALIFYING TRADE(S) 0018 FENCE a 11 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHAIN LINK FENCE DESIGN DETAIL (ACCORDING TO THE F.B.C. SECTION R4408.11) TABLE R4408.11 CHAIN LINK FENCE MINIMUM REQUEREMENTS Fence Height (ft) Terminal Post Dimensions (in inches) (o.d. X wall thickness) Line Post Dimensions (in inches) (o.d. X wall thickness) Terminal Post Concrete Foundation Size (diameter X depth) (in inches) Line Post Concrete Foundation Size (diameter X depth) (in inches) Upto4 11 23/8x0.042 15/8x0.047 10x24 8x24 Over 4 tc5 j 2 3/8 x 0.042 1 7/8 x 0.055 10 x 24 8 x 24 For SI: 1 inch = 25.4 mm. NOTES: 1. This table is applicable only to fences with unrestricted airflow. 2. Fabric: 12 1/2 gauge minimum. 3. Tension bands: Use one less than the height of the fence in feet evenly spaced. 4. Fabric Ties: Must minimum the same gauge of the fabric. 5. Fabric Tie Spacing on the Top Rail: Five ties between posts evenly spaced. 6. Fabric Tie Spacing on Line Posts: One less than height of the fence in feet, evenly spaced. 7. Either top rail or top tension wire shall be used. 8. Braces must be used at Terminal Posts if top tension wire is used instead of Top Rail. 9. Post Spacing: 10 foot (3m) on center maximum. 10. PoSt shall be embedded to within 6 inches (152 mm) from bottom of the foundation. 11. In Order to follow the contour of the land, the bottom of the fence may clear the contour of the ground by up to 5 inch (127 mm) without increasing table values to the next higher limit. NOTICE TO PROPERTIES WITH POOLS: If the fence Is to meet the criteria as a pool barrier, the fence shall not be climbable and all rails must be placed facing the inside of the property. Pedestrian gates shall have self - closing and latching devices installed at the minimum of 54" above ground. For further details see Section R4401.7.1 of FBC. CONCURRED Created on 5/22/2009 MLDV /L JUN ORDERED BY: PEITDI °3.QN TITLE SERVICES Robert: I Perdflgon ! 305.670.3707 rperdigon perdlgontftle.com One Datran. Center PHI. Suite 1701 Miami,' FL 33156 Face 305670.3711 Miami Beach Office } 1681 Michigan Ave Suite 1001 Miami Beach, R 33139 PROPERTYADDRESS: 10301 N. MIAMI AVENUE MIAMI SHORES, FLORIDA 33150 FIELD WORK DATE: 5/282014 F114053205 _ AsAAADADEcomy L1S S 00'00'00" W 219.11' P) R =28:00' P&M) S 0'14'46" E 220.82' (Mt L=39.03' ''P) 38.57' M) REVISION DATE(S): (REV.1 5/29/2014) SURVEY NUMBER: FL1405.3206 N.W. 104TH STR NO ID 0 P.I. S 89'26'20" E 40.00' (P a 88'26'20 "(P) 4'04 "(M) N 89•45'14" E 40.001-(M) N 44•43'10'.' WW 35.18'(P) NDtES N 44'59'14" K. 34.86'(M) LOT APPEARS TO BE SERVICED BY CITY WATER AND SEWER FENCE OWNERSHIP NOT MEOWED LOT 12 ILK 123 -3"\ 21.9' c .6' 1 STY. RES #10301 28.6' 27.6' LOT 14 BLK • 123 Air Ado, Air AidrrAiffiff 416WAir Ad hereo my dir - an lis,M A mat and belle , 't is of a survey the standards set fo r e =s'he ',f; y ttfiaffori a e Professional Survey. p' in Chapter. 5J -17 of the Florida < � e Code. - RONALD W. WALLING State of Florida Professional Surveyor and Map License No. 6473 P® ���Auti /ice• SUBJECT TO COMPLIANCE wrTHALL FEDERAL " °° STATE AND COUNTY RUB AND REGULATIONS Use of This Survey for Purposes other than Intended, Without Written Verification, will be at the User's Sole Risk and Without Liability to the Surveyor. Nothing hereon shall be Construed toque ANY Rights or Benefits to Anyone Other than those Certified. tif4RRs BLDG DEPT Miami Shores Village B iildin Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 0( 6 2 -4 "t T 1�1c5 el: (305) 795.2204 Fax: (305) 756.8972 BUILDING Permit No. t \ -4-010- s5•3 PERMIT APPLICATION FBC 2004 B CMaIVi��' APR 04 2006 JL Master Permit No. Permit Type (circle uiltling / Electrical Plumbing Mechanical Owner's Name (Fee Simple Titleholder)) t ,1/i- ,I- Phone # e 5 r 7 Owner's Address /6 .-3Z) / ! i 7 01/7171/ / / S t City./44-m/ 076-5° State ri-, Zip g3 /.tee Tenant/Lessee Name Phone # Job Address (where the work is being done) /6' City Mi Shores Vill e C FOLIO / PARCEL # M. 1/ 2 !3& d is Is Building Historically Designated YES Contractor's Company name Contractor's Address 4 Miami -Dade NO V Roofing Zip 53/50 Phone # City State Phone # Qualifier Name PC State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Value of Work For this Permit $ 4- Phone # Squar /Linear ootage Of Wo Type of Work: DAddition ` DAlieration New Repair/Replace Demolition Describe Work: 5 - Chh-i,v % /4' Aim/ /(3ie/ dwGLP. n i .4264 (.hit i L,`n k i- `o,t.c e. 41.6-1 tv/iugv- 44J-re eit-64�� C� "Sri-) ehai, ex /10. S.; le /kale Submittal Fee $ Permit Fie $ CCF $ CO /CC Notary $ Training/Education Fee $ Technology Fee $ Scanning $ Radon $ DPBR $ Zoning $ Bond $ Code Enforceii►ent $1 Double Fee $ Structural Review. $ Total Fee Now Due $ See Reverse ide --4 Bonding Company's Name (if applicable) 14 Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) 4/4 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 AF'HDAVIT: 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 witbestimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and co ?roc n lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the rec otice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the buildin;. .t is issued. In the absence of such posted notice, the inspection will not beppproved and a re •ction fee will be charged. goo / 411411. Signature /j ! 11,1 1i "gnature er or Agent The foregoing instrument was acknowledged before me this 4` The foregoing instrument was acknowledged before me this day of kr l , 20 _, by 4604'tin , day of , 20 , , by who is personally known to me or who has produced 17, -Dalt is who is personally known to me or who has produced P635 ° '¢7 Vis identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: Contractor Sign: Print: sooTit,144 MONlCA LISSEtH DIAZ ->r 4 MY COMMISSION # DD 483995 • r20 2009 Bortad My Commission Expires: ** , t, r*** *,tt,r,r,r**** *** **,r **** *,ter** *,r** r*** ** * *** ***** ***** ter * *, , * * * * **** * ** * *, r, r******* *** ******** *** * * **** NOTARY PUBLIC: Sign: Print: My Commission Expires: APPLICATION APPROVED BY: (Revised 02/08/06) D� Plans Examiner V Engineer Zoning