CAMELIA ST 451 M1,3844
OtPARTMAT OF BUILDING
CITY OF ATLANTIC BEACH
----- PERMIT, INFOR."floN ------- LOCATION INFORMAT ION
Permit Number: , , 1,5003 Address : 451 CAMZLIA .gTR
Permit Type;PLUMB ING
ATLANTIC BEACH, FLORIDA 32233
Class o f Work:AtTZRATION L10AL DESCRIPTION -------
Constr . Tyti AM Block. 'T 0
wp:
Proposed Us*�.,SINQLE FAXILY Section: 02, subd� Rfi 01
Dwell in4 I 1 11 Ir i
_s: 0 'Subdivision-,
Est . Value, 0.06,
Im1prov. Cost :
'Total 25 .00
Amount 25.01D
k
M,;��Alq "via 4�1
ION
APPLICATION FEES-
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�NOTES:,
NOTICE-INSPECTIONS MUST BE REQUESTED AT LEAST 24 HOUR$PRIOR TO INSPE
CT104
BUILDING MATERIAL,RUBBISH,AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLICSPACE,ANDMUST BE
CLEARED UP AND HAULED AWAY BYEITHER CONTRACTOR OR OWNER
1-T
�ULT IN
"FAILUM M-COMPLY WITHTHE MECHANICS' LIEN. LAW CAN RES
THE PROP ERTY OWNER P I AYING TWICE FOR SUIL 01 1 NG Mp Ekik�,fs
''ISSUED
ACCORDING TO APPROVED"PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO PEVOCATION FOA
VIOLATION OF APPLICABLE PROVISIONS Of LAW.
Met
oat,
ATLANTIC BEACH BUILDING DEPARTMENT
By:
ZZ:711
4OV-19-93 FRI 22 : 10 RICHARD A MILLER & ASSOC 904 721 5758 P. 04
MAP SHOWING SURVEY OF
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AS RECORDED IN PLAT BOOK 181 PAGES 5 4 ---OF THE CURRENT PU13LIO RECORDS OF- R 2VA L- COUNTY, FLORMA.
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MAP SHOWING SURVE"F--
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FAB RECORDED IN PLAT BOOK PAGES 54 OF THE CURRENT PUBLIC RECORDS OF- COUNTY, FLORIDA,
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AS nEconDED IN PLAT BOOK—La—PAGES 34 OF THE CURRENT PUBLIC RECORDS OF' COUNTY. FLORIDA.
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MAP SHOWING SURVEY OF
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AS AECORDIED IN PLAT BOOK - 18 PAGES 54 --OF THE CURRENT PUBLIC RECORDS OF- -COUNTY, FLORIDA,
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MAPSHOWINCISURVEY OF
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AS RECOADE0 IN PLAT BOOK--LO—PAGES 34 OF THE GURSENT PUBLIC RECORDS OF
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CITY OF ATLANTIC BEACH
Fixture Unit Worksheet for Water Impact Fee
FIXTURE UNITS ARE ESTABLISHED AS THE MEASUREMENT OF WATER DEMAND FOR
EACH WATER FIXTURE UNIT INSTALLED AND CONNECTED TO THE CITY WATER
SYSTEM. THE WATER SUPPLY CHARGE IS HEREBY FIXED AT TWENTY DOLLARS
PER FIXTURE UNIT CONNECTED TO THE CITY WATER SYSTEM.
BATHROOM GROUP CONSISTING OF SERVICE SINK TRAP STAND
WATER CLOSET, LAVATORY & BATH (8)
TUB OR SHOWER STALL (6) 1 2-
WATER CLOSET
WATER CLOSET, TANK OPERATED (4) VALVE OPERATED (8)
:LBATHTUB/SHOWER (2) URINAL WALL LIP (4)
SHOWER GROUP PER HEAD (3) FLOOR DRAIN (1)
SHOWER STALL DOMESTIC (2) LAUNDRY TRAY (2)
LAVATORY (1) COMBINATION SINK AND TRAY (3)
—�—WASHING MACHINE (3) POT, SCULLERY SINK (4)
_I_DISHWASHER (2) WASH SINK EACH SET OF
_KITCHEN SINK (2) FAUCETS (2)
DENTAL LAVATORY (1)
KITCHEN SINK WITH WASTE DENTAL UNIT OR CUSPIDOR (1)
GRINDER (3)
BIDET (3) URINAL STALL, WASHOUT (4)
FLUSHING RIM SINK (8) COMBINATION SINK AND TRAY WITH
FOOD DISPOS. (4)
URINAL, PEDESTAL, SYPHON JET DRINKING FOUNTAIN (1/2)
BLOWOUT (2)
LAVATORY, BARBER/BEAUTY ICE MAKER (1/2)
SHOP (2)
SURGEONS SINK (3) LAVATORY, SURGEONS (2)
JACUZZI (2) 0 URINAL STALL, WASHOUT (4)
TOTAL FIXTURE UNITS @ $20.00 EACH $ 3
JOB INFORMATION Y
C
CITY OF
4&40dw Beoc,4-11au'd44
Office of Building Official
REQUEST FOR INSPECTION
Date Permit No.
Time 3 A.M.
Received RM.
Owner's Job c1dress 1Y cality t
Name -4t��Contractor
BUILDING CONCRETE ELECTRICAL C'�LUMBING-,'--�> MECHANICAL
Framing D Footing El Rough Wiring El Rough
Re Roofing El Slab e><Air Cond. &
El Temp Pole El Top Out 1:1 Heating
Insulation 11 Lintel D Final 0 Sewer 0 Fire Place
READY FOR INSPECTIO Pro Fab
Mon. Tues. Wed. A M.
PM.
Inspection Made M.,
:;;��Fn.l Inspection P
Inspector- Certificate of Occupancy El
Date
CITY OF
4&4a& Be"4-11ou'da
Office of Building Official
REQUEST FOR INSPECTION
Date Permit No. 7755-
Time A M
Received M.
V.
Owner's Job Ndress ��&�Locality
Name Contractor
BUILDING CONCRETE ELECTRICAL (--PLIJIMB G MECHANICAL
Framing D Footing 11 Rough Wiring 1:1 Air Cond. & 11
Re Roofing
11 Slab El Temp Pole El Top Out El Heating
Insulation El Lintel El Final 11 Sewer 1:1 Fire Place 1-1
Pre Fab
READY FOR INSPECTION
A M.
Mon. Tues. Wed.
P.M.
Inspection Made
Inspector- Final Inspection El
Certificate of Occupancy El
Date
9-9,-Iiola
WWI -114w-
=1A.S. Zia
<4TVAL CACOM
-.Wlo�r*4 1"S. 15.
1-7
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1673
LAN
ORI
CITY OF ATLANTIC BEACH
CODE ENFORCEMENT DIVISION
800 Seminole Road
Atlantic Beach, Florida 32233
PHONE: 247,5855
COURTESY
NOTICE OF VIOLATION
DATE /
TIME
OWNER/OCCUPANT
A 4-27-
ADDRESS
THE INSPECTION MADE OF THE ABOVE PREMISES
THIS DATE DISCLOSED YOU WERE IN VIOLATION OF
ORDINANCE:
OF THE CODE OF THE CITY OF ATLANTIC BEACH,
FLORIDA.
YOU CAN COMPLY BY.,1-14b-
WITHIN 0 DAYS OF THIS NOTICE
THIS IS A COURTESY NOTICE IN ORDER TO MAKE
YOU AWARE OF A VIOLATION OF THE CITY CODE
OF ATLANTIC BEACH. IF YOU HAVE ANY QUESTIONS
OR WOULD LIKE ADDITIONAL INFORMATION
PERTAINING TO THIS NOTICE, PLEASE CALL
ATLANTIC BEACH CODE ENFORCENfF.NT OFFICE.
CODE ENFORCEMENT OFFfCER
RECEIVED BY
ADDRESS
BUILDING PERMIT NUMBER_ 76
INSPECTIONS : FOOTING
UNDER SLA B PLUMBING
SLAB 1-7-
FRAMING
COVER-UP-
INSULATION 9-
FINAL BUILDING
CERTIFICATE OF OCCUPANCY
ELECTRICAL PERMIT #
INSPECTIONS ROUGH
FINAL
MECHANICAL PERMIT # �,9,9 7
--7
PLUMBING PERMIT 21
NOTES:
CITY OF ATLANTIC BEACH
APPLICATION FOR PLUMBING PERMIT
JOB LOCATION:
OWNER OF PROPERTY: LA
PLUMBING CONTRACTOR: 14)
CONTRACTOR'S ADDRESS:
STATE LICENSE NUMBER: TELEPHONE:
HOW H�Y OF THE FOLLOWING FIXTURES INSTALLED
SINKS SHOWERS
LAVATORIES WATER HEATERS
BATH TUBS DISHWASHERS
URINALS DISPOSALS
CLOSETS WASHING MACHINES
FLOOR DRAINS SHOWER PANS
OTHER
TOTAL FIXTURES: X 3.50 + $15.00 Z
MINIMULM PERMIT FEE $25.00
SIGNATURE OF OWNER:
SIGNATURE OF CONTRACTOR:
----------------------------------------- ---------------------------
INSTALLATION OF PLUMBING AND FIXTURES MUST BE IN ACCORDANCE WITH THE 1994
STANDARD PLUMBING CODE.
CALL A DAY AHEAD TO SCHEDULE INSPECTIONS - (904) 247-5826
SEWER CONNECTIONS MUST BE CALLED IN TO PUBLIC WORKS FOR INSPECTION PRIOR
TO COVERING UP - (904) 2-47-5834.
7828
DEPARTMENT OF BUILDika�
CITY OF ATLANTIC BEACH
PERMIT INFORM TION -
-------- LOCATION INFORMATION --I-------
Pe rmi,t, ,Numbe r,,*
Addrest,�'.. 451 CAMELIA STREET
CHAN
Petmit typ4v-� -ME ICAL,
H ORIDA 32233
C a' ATLANTIC BEAC PL
I ss- of Work� NZW� ` -------
LEGAL DESCRIPTION ----------
Type*- WOOD FRAME 'k.
Lot * � Bloc Sectiow
Prop' osed Usol DUPLEX
Township: RNG*� 0
gs,*,
i I in ode, S
ubdivision: SECTION H
Valve,
1ppt�ov. cot t,�- $6.00
OtAl
$43 .00
.1-6 A
'r awn 1%T A , IN *xw,
TRAT RVA
t,D"Or-i 0mg
N APPLICATION FEES
'PERMIT $43.00'
A STREET
IMPACT, PEE 0 $0-00 ,
R FLOR
Ph AM iKAP
0
RADi N ',GAS-H.R.S.
7!- ------ -1
RADON CAB
Na CMITAL- IMPROVE
0 0 0
'34 -SEWER TAP $0.6o
JACK 1 , , FLORIDA 32216 ' HYDRAULIC SHARE
Type, CROSS CONNECTION. *J,�,,00 ,
C.H, IMPACV, FEE
�7
7777
lip
TICV�,: ALL doft� IETE FORMS-AND FOOTINGS MUST BE INSPECTED BEFORE POURING.
PERMIT VOID SIX MONTHS AFTER DATEOF ISSUE
'a"61�6*G MATERIAL�,RIUSBIISHI AND-10EIBRIS PROM THIS WORK MUST NOTSE PLACED IN PUBLIC SPACE,AND MUST BE
0,H A ULAD AWAY BY,F-!THER CONTRACTOR OR OWNER
EOUPAN
*TAILIVAE:T0,,,C0.IVIPLY1"*1TH TH E MrZC HAN LIE N LA -R $ULT IN
W CANL
OpItft PAYING TWICETOR BUtOING IMPROMEOVIENTSt
I U 0 ORD04- VEP,PLANS WAI 'D SUBJECT TO REVOCATION FOR;
66 t Adt iG,TO4 PRO CH ARE PART OF THIS PERMIT AN
F�APP�%'
00yiSIONSOFlAW.
v
0000ww 00000m
:PART1.0 NT -
PCO". 000045
&47
77
DEPART ENT 0.0 OUILD1140
m
CITY OF ATLANTIC BE'AdH
�`-�-�;`PERMIT INFORMATION. -------- -
LOCATION INFORMATION
Address: 453 CAMELIA STREET
f0trait Type, MECHANICAL
ATLANTIC BEACH, FLORIDA 32233
I As$ f Wo r k-, NEW�
--------- LEGAL DES'CRIPTION ---------- -
,,Co,nstr,., Type; WOOD", FRAME Section:
�ed Use DUPLEX G
Township. RN
lnqS : 'I Code� 0 Subdivision: SECT I ON H
Value�-
IrAlprov . Cost ,
T�
t
Amoun, $0.00
RIM
fft t 11 till" !m"PtEx ""TT
jw,
TION 4%7v-4- -l", kol --- APPLICATION FEES -----
PERMIT $43 �00
IMPAC FEE 471
A STREET g,'
41 IP WA 90
"'gi
FF L OR I q05
P p 'Y4A R AP .00
RADON GAS-H R S
$0 ,00
R7 FORMATIi ------ - RADON CAB 5%, $0 .00
CAPITAL- IMPROVE ---S0,;00
NaMe
aL
JOHNS BLUFF SEWER TAP WOO
J,A C K, LLE,- FLORIDA 32216 HYDRAULIC SHARE
.00
$0 A�0
11 a e . Type. 3 CROSS CONNE "
CTION
CONST. SURCHARGE
'ALL CONC09TE FORMS AND.FOOTINGS MUST BE INSPECTED BEFORE POURING
14OTICE-
PERMIT VOID.SIX MONTHS AFTER DATE OF ISSUE
7�
MAT-F-AIAL,,,RUSSi$H,.�ND:DEB,R-IS FROM THIS WORK MUST NOTSE PLACED IN PUBLIC SPACE,AND MUSTSE
�,�,,:�CLEAREDLUPANDJIAUL 0AWAY BYEITHER CONTRACTOR 60 OWNER
W
�TAIL'LURE TO,COMPt*WITH THE MECHANICS ,, LIENLA CANRESULTIN
P
OPE"dWNJM PAYING TWICE.FOR BUILDING, IMPROVEMENTS.
C I'Nd TOAPO'ROVED PLANS WHICH ARE PART OF THIS PERM T AND SUBJECT TO REVOCATION,FOR
OoApk
OLE P
SIONS'CIF LAW.
al
A' N
TLANTIC;BEACH,SUI�01 RTM
ENT 00000W 0000OWK) $43A 14
7/9401 Rcpti 00L17046
Date: VOL
4-
TRANSMITTAL DOCUKENT R* JEA
DATE:
The following permits have passed "rough" inspection:
Permit No. Address
'�4�7-79 9 4/5/ 00/nie//Q*
2c��'73 o J44ce07-
Please update
your records accordingly.
n
LDI7/
CITY OF ATLANTIC BEACH
/vcb
7
DATE. -, -----------
PRE-SERVICE DIVISION
JACKSONVILLE ELECTRIC AUTHORITY
233 WEST DUVAL STREET
JACKSONVILLE, FLORIDA 32202
THE FOLLOWING FINAL INSPECTION(S) HAVE BEEN MADE AND ARE
SATISFACTORY:
----------
------ ---- -------------------------
---------------
_7-r-
----------------
-------------
Enclosed are the blue copies of the permits.
SINCERELY,
'7- Z_,/_
BUILDING INSPECTION DIVISION
cc:FILE
CIT7 OF ATLANTIC BEACH PFMIT CALCULATIOV SHEET
Ac1dress—.., . ,&,Ez--. 0!5:,l(/t S7-
Date Jd — /�3 - ;"-3
Heated Square Footage per sq f t = S�//�
Garage/Shed __ per sq ft = $
Carport/Porch per sq ft. = $
Deck per sq ft = $
Patio 06 @ $ 00 per aq ft, = $
TOTAL VALUATION:
/
To��J Valuation ist. $ /I
z 0 0
Remaining Value $,t—. per thousand
or portion thereof
TOTAL BUILDING FEE S
+ 1/2 Filing Fee
Q ) Fireplaces @ $15.00 ts-.00
BUILDING PERMIT FEE
WATER IMPACT FEE
SEWER IMPACT FEE $
WATER METER/TAP 140'.
CAPITAL IMPROVEMENT $
SEWER TAP $,
Ql&-5) RADON (HRS) .0045 $
RADON (CAB) ,0005 $
SECTION H PAVING ( 5-o $ 750
HYDRAULIC SHARES
CROSS CONNECTION $ zs-.03
(1(6'5) SURCHARGE .0050 $ 17.81 '0-
OTHER $
GRAND TOTAL DUE $
ADDITIONAL PERMITS OR FEES: Mechanical_; Plumbing
Electric/New Electric/Temp_;SwimmingPool
Septic Tank Well Sign Finish Floor Elevation
Survey other_
CALCULATIONS and/or NOTES:
CITT! OF AT1,119TIC BEACH PRRNIT CALCULPATIOV SHEN?
A,i(lress— S7-
Date /--3
Heated Square Footage per xq ft = $ Z//), 's
Garage/Shed $ per aq ft =
Carport/Porch $ --per sq ft =
Deck —16 $ jper aq f t $
Patio j 66 _- a $--!�106-..per sq ft q00,0 0
TOTAL, VALUATION:
Total Valuation Ist.
Rema,Ining Value $,T-. per thousand
or portion thereof
TOTAL BUILDING PER
+ 1/2 Filing Fee $
( 1 ) Fireplaces 6 $15-00 $
BUILDING PERMIT FEE
WATER IMPACT FEE $
SEWER IMPACT PER $
WATER MZTRR/TAP $
CAPITAL IMPROVEMENT
SRNRR TAP
Q14-5) RADON MRA) .0045
RADON MR) 0 0005
SECTION K PAVING ( ,5-0/ ) $ IiO
HYDRAULIC SKAR98
CROSS CONNSCTION
(116'5) SURCUAROZ .0050 $
OTHIR $
GRAND TOTAL DUN s
ADDITIONAL PERMITS OR FEES: Mechanical_; Plumbing
Electric/New Electric/Temp_;BwimmingPool
Septic Tank_ Well Sign rinish Floor Elevation
S ; Other-
Survey
CALCULATIONS and/or NOTES:
DEPARTMENT OF BUILDING
CITY OF ATLANTIC BEACH
--, PERMIT INFORMATION ------ --- ----- LOCATION INFORMATION ---------
Permit Number: 7652 Address: 451 CAMELIA STREET
Permit Type: BUILDING ATLANTIC BEACH, FLORIDA 32233
Class of Work: NEW --- ------- LEGAL DESCRIPTION ----------
Constr Tgge: FRAME Loi : 2 BlRQk: 107 Rption6 H
Propos4d e: MUM Towns ip:
Dwellings: 1 Code: 0 Suldivision: SECTION H
Estimated Value: $41686. 50
Improv. Cost: $0 .00
Total Fees : $3211 . 64
Amount Pai 9,, $3211. 64
Date P&A, J93
Work Desc. -" , .DUPLEX UNIT PER PLANS HSF 1163
-- -------- -
ION ------
Name: DE
C;&MIT $345.00
Addres STREET WATER IMPACT FEE .00
CH, FL 3�22 S
$V21'0
t4WER iD�%0 0
Phone: 3
*- R Z.4L7
RADON GAS-H.R.S. $5. 24
------- CON T N TION RADON GAS - 5% $0 . 58
Name: DEA RU L STRUC CO. CAPITAL IMPROVE. $n� 5,�00 ,
9"k. I_ ' I --_SEWER $0 .00
Ad dr ess_-1-4-15-30 HIR --STREET-..-
JACKSONV BEACH, FL 32250 HYDRAULIC SHARE $0 .00
License: 06 ' Type: 10 CROSS CONNECTION $35.00,
SEC.H IMPACT FEE .00
NOTES:
NOTICE-ALL CONCRETE FORMS AND FOOTINGS MUST BE INSPECTED BEFORE POURING
PERMIT VOID SIX MONTHS AFTER DATE OF ISSUE
BUILDING MATERIAL,RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE
CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER
"FAILURE TO COMPLY WITH THE MECHANICS' LIEN LAW CAN RESULT IN
THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS.99
ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR
VIOLATION OF APPLICABLE PROVISIONS OF LAW.
ATLANTIC BEACH BUILDING DEPARTMENT
By: JOB COP)
ef
CITY OF ATLANTIC BEACH
Fixture Unit Worksheet for Water Impact Fee
FIXTURE UNITS ARE ESTABLISHED AS THE MEASUREMENT OF WATER DEMAND FOR
EACH WATER FIXTURE UNIT INSTALLED AND CONNECTED TO THE CITY WATER
SYSTEM. THE WATER SUPPLY CHARGE IS HEREBY FIXED AT TWENTY DOLLARS
PER FIXTURE UNIT CONNECTED TO THE CITY WATER SYSTEM.
BATHROOM GROUP CONSISTING OF SERVICE SINK TRAP STAND
WATER CLOSET, LAVATORY & BATH (8)
TUB OR SHOWER STALL (6) 21
WATER CLOSFT
WATER CLOSET, TANK OPERATED (4) VALVE OPERATED (8)
BATHTUB/SHOWER (2) TUIRINAL WALL LIP (4)
SHOWER GROUP PER HEAD (3) FLOOR DRAIN (1)
SHOWER STALL DOMESTIC (2) LAUNDRY TRAY (2)
LAVATORY (1) COMBINATION SINK AND TRAY (3)
WASHING MACHINE (3) POT, SCULLERY SINK (4)
__�_DISHWASHER (2) WASH SINK EACH SET OF
0 KITCHEN SINK (2) FAUCETS (2)
DENTAL LAVATORY (1)
KITCHEN SINK WITH WASTEf�) DENTAL UNIT OR CUSPIDOR (1)
GRINDER (3)
BIDET (3j URINAL STALL, WASHOUT (4)
FLUSHING RIM SINK (8) COMBINATION SINK AND TRAY WITH
FOOD DISPOS. (4)
URINAL, PEDESTAL, SYPHON JET t1DIRINKING FOUNTAIN (1/2)
BLOWOUT (2)
LAVATORY, BARBER/BEAUTY ICE MAKER (1/2) f
SHOP (2)
SURGEONS SINK (3) LAVATORY, SURGEONS (2)
JACUZZI (2) URINAL STALL, WASHOUT �(4)
TOTAL FIXTURE UNITS, ao' @ $20-00 EACH $ e0o' ob
JOB INFORMATION
FLOODPLAIII DEVELOPHENT I11FORHATIO11
Type of Developments
Flood Zones
Required Lowest Floor Elevations
If building is located within a flood hazard zone, a survey must
be made AFTER THE SLAB HAS BEEII POURED, certifying that the
LOWEST FLOOR ELEVATION in equal to or above the base flood
elevation established for,. that zone.
110 final inspection will be made and no certificate of occupancy
will be Issued until the survey is on file with the Building
Department.
GUHHENTS:
Applicant Acknowledgementi I understand that the issuance of
this Permit is contingent upon the above information being
correct and that the plans and supporting data have been or shall
be provided as required. I agree to comply with all applicable
Provisions of Ordinance No. 25-7-11 and all other laws or
ordinances affecting the proposed development.
Date-A/1 3 19/�? ...Applicant's Signature
A!�
----------------------------------------------------
Department Use
Required Lowest Floor Elevation
An Built Lowest Floor Elevation
Survey Filed with Building Department ...........
-----------------------------------
Building Department Representative
page 3
'PROPERTY DESCRIPTION W I
11�darfirtc gedelt - 2(ov
7 16 OCFAN 13OUEVARD
Lot 0---L,��Block C)- Section 0 1'.0.BOX 25
1993
ATLANI IC BEACII,FLORIDA 32233
TEMENIONE(9041249-2395
Subdivisions ---------------------- and Zoqlng
Street flame DESCRIPTIOR OF WORK
or Addreass
11 in a FLOOD HAZARD
Flood Zonei__ area complete page 3. Brief
\----------
'ICIZ 0�uj
Descriptions_
Class of Works
(flew/Remodel/Addi t ion)
Z011ING 111FORHATION
Type of
Construction: &
Zoning Proposed '07Q
Dintricts-?'(SU)t Use 3 Estimated Value 4; f2
Exceptions or
-nit Lc?fj I
Vni-invican Ux ___Uj VT----------------- Solid or
Filled
0 r o u n d s_iEk"4ES�, Hoofs
0WHER 111FURHAT1011
Hothod of 11ratisigi-
Property Owne-ro—L) PlIonel
L ------------------- --ZL43-------- -
"niling
Address
pn Zips
------------------------------
COUTRACTOR INFORHATION
Coll trnctor
Phones
Hailing
A d d r e a a i --------ILI
----------------- -------- zips
Expiration
License I I u m b e r I Dote i
I IlEnERY CrRTIFY TIIAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW TnE SAME TO PE TRUE
Aton connECT, ALL rnoyisxons OF THE LAWS AND ORDINANCES COVER141140 T11IS Tyrc or wonK vil.t PF
COMPLIED WITH, witrTnrn SPECIFIED nEnrin OR NOT. THE ORA"TING or A PERMir noEg NOT rnESUMF TO
OIVF Atmtonm TO VIOLATE On CARCEL THE PROVISIONS OF ARY rEDEnAL, STATE on LOCAL nULEr,
PFOULATIO115, onDiNAHCrS, OR LAWS IN ANY MANNER, INCLUDINO THE COVERNINO OF CONSTRUCTION OR THE
rrnrunMA?ft;E OF CONSTRUCTION OF T11E PROJECT. I UNDERSTAND TNAT THE ISSUANCE OF T11IS rF:RMtT 19
COUTINVENT urO" T1fR ASOVE INFORMATION BEINO TRUE AND CORRECT AND THAT THE PLANS AND SUPPOnTIHO
DATA HAVE BEEN an SHALL BE PROVIDED AS REOUIRED.
Owner Signature ------ -----------Date/,(Auzp_�__
Contractor Signature Date