Permit Remodel 373 6th St 2011 j -
, CITY OF ATLANTIC BEACH
s 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
"- .0;11
Application Number 11- 00002569 Date 9/02/11
Property Address 373 6TH ST
Application type description RESIDENTIAL OTHER
Property Zoning TO BE UPDATED
Application valuation . . . 15000
Application desc
REMODEL BATH AND KITCHEN
Owner Contractor
LINDLEY TOLERT DESIGNS GENESIS BUILDING CORP
465 BEACH AVENUE 2158 MAYPORT RD.
ATLANTIC BEACH FL 32233 ATLANTIC BEACH FL 32233
(904) 241 -0320
Permit RESIDENTIAL ALT /OTHER
Additional desc .
Permit Fee . . . 125.00 Plan Check Fee . . 62.50
Issue Date . . . Valuation . . . . 15000
Expiration Date . 2/29/12
Special Notes and Comments
*2007 FLORIDA BUILDING CODE W/2009 REVISIONS
NATIONA1 ELECTRIC CODE
*REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING
DEPARTMENT IMMEDIATELY.
Other Fees STATE DCA SURCHARGE 2.00
STATE DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 125.00 125.00 .00 .00
Plan Check Total 62.50 62.50 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 191.50 191.50 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 -5845
Job Address: 1 3 6 - 44,, ---f i'c-- /C Permit Number: //- o`? 5'6 9
Legal Description "o - 2S ) ' 4i-tz,,,-4 c. /act. Parcel #
Floor Area of Sq.Ft. lyZ Sq.Ft y
Valuation of Work $ / 4• Proposed Work heated /cooled non - heated /cooled
Class of Work (circle one): New Addition Alteration Repair Move 'Demolition pool/spa window /door
Use of existing/proposed structures) (circle one): Commercial : - idenf .
If an existing structure, is a fire sprink1er s stem installed? (Circle one): -`' es No N /A
Florida Product Approval # .
For multiple products use pro uc pp orm S 2
Describe in detail the type of work to be performed: °- B * 1 i&MUDer_ 4-
Property Owner Information:
Name: k t 4 0 /: I 1 1 f: Address: 1 &*tA
City MIMI i ' ,, State i ip ZZ " hone qo4 t Z . i 7 1 ( )
E -Mai or Fax # (Optional)
Contractor Information:
Company Name: 6.- es -re5f5 y'3l - Coy 0 ,.).5c-a (05 its— Qu la ifyin Agent: "" - rod 5c-,
Address: S a City )4¢ --/ ° C. f. State p Zip 3.1.2_ 3 3
Office Phone `/ Y 0 Job Site/ Contact Number 233-- (60 (-7 Fax # 9''6 y /d,3J 4
State Certification/Registration # C 1 2-Y - 62/2,
Architect Name & Phone #
Engineer's Name & Phone #
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and Address
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. This permit becomes null
and void if work is not commenced within six (6) months, or if construction or work is suspended or abandoned for a period of six (6) months at any time after
work is commenced. I understand that separate permits must be secured for ElectricalWork, Plumbing, Signs, Wells, Pools, F urnaces, Bo Heaters,
Tanks and Air Conditioners, etc.
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.
1 hereby certify that I have read and examined this a' ilication and know the same to be true and correct. All provisions of laws and ordinances governing this
type of work will be complied with whe r sp herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any other fed al, s i • or o al i, lati : onstruction or the performance of construction.
Signature of Owner 1 _ __ , 5 , Signature of Contracto
Print Name 17N2i1 Print Name ( OGid Q�-
�,D
Sworn to and subscribed before me Sworn to and subscribed before me
this 3u Day of )49 us-/ , 20 / l this c -A, ') Day of a9c/Se - / , 20 if
Notary Public Notary P u b lic
WILLIAM L POPE Revised 01.26.10
Notary Public, State of Florida WILLIAM L POPE
Notary Public, State of Florida
My comm. exp. Oct 19, 2011 My comm. exp. Oct 19, 2011
Ca 0, D 16�.. , ; * }4y \ Comm. No DD 714216 volvimne 4
'REVIEWED FOR CODE COMPLIANCE
F' I L E CITY OF
J � P � ^ ; ATLANTIC BEACH
y ,„ _ F ' SEE PERMITS FOR ADDITIONAL
R EQUIREMENTS AND CON a TI i NS.
i
1 /al / / REVIEWED BY: I / , r • r 7-7- ii
..� .
/S v . /Ln w
Doc 4 2011190885, OR BK 15700 Page 1518,
Number Pages: 1
Recorded 08131;2011 at 12:07 PM,
JIM FULLER CLERK CIRCUIT COURT DUVAL
COUNTY
RECORDING $10.00
Permit number // 9 Tax Folio number
NOTICE OF COMMENCEMENT
STATE OF FLORIDA
COUNTY OF DUVAL
THE UNDERSIDED hereby gives notice that improvement 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. Description of property:
3 . S�r--e.ci- A'c 69..o .c_ 5),) 6 9 / -.2 5 .-5 -,4 i' ,,; -A'c
2. General description of improvements:
3. Owner information:
a. Name Adds
�r\A rA t QA l U 1 �eJ1; -(" ' e( ln, \ \AC° - 51 C �•-
,9t
b. Interest in pr
C)1 .On
c. Name and address of fee simple titleholder (other than owner): 6
4. Contractor's name and address:
��-.► e5 /3 1?i l.I ( a1P D64 62..0)5c° (J5 -� /- - 5 57f (Yt 'uT 3�13�
h� a. Phone number: � 02/7 ) b. Fax numb " 7-1- / /
5. Surety information:
a. Nance and address:
b. Phone number. c. Fax number: d. Amount of bond:
6. Lender's name and address: .
a. Phone number: b. Fax number:
7. Person within the State of Florida designed by owner upon whom notices or other documents
maybe served as provided by 713.12(1)(a), Florida Statues.
Name and Address:
a. Phone number: b. Fax number:
8. In addition to himself/herself, owner designates
of to receive a copy of the Lienor's Notice as provided in
Section 713.12(1)(b), Florida Statutes.
9. Expiration date of Notice of Commencement (the expiration date is one (1) year from the
date of Recording • less . di . - - . t .►: to s • ' - -. .
s
Signature of Owne . ik
Sworn to and subscribed before me this 30 day of car, 20 / / - � •
Notary: /de/A, , Z , ,ir,P 91,014 00 'ON 'wino Gi
40Z '61 l00 'dxg •ww03 AN
11 /ID shown: a bold to awls . 31mnd AieloN
Y My commission expire: 3d0d 1 WtJI111M
A. U. S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT R. TYPE OF LOAN
SETTLEMENT STATEMENT
The Law Offices of Rod Schloth, P.A. 1. ❑ FHA 2. ❑ FMHA 3 ! CONV. UNINS
2187 South Third Street a. VA 5. U CONV.INS.
Jacksonville Beach, Florida 32250
904 -372 -9351 fax: 904-372-9230 6. File Numbs 7 Loan Number
R$11 -213
B. Monage In Case No
C. NOTE This form is furnished to ,give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked
(Poe) were paid outside the closing. They are shown here for informational purposes and are not included in the totals,
Lindley Tolbert Design, Inc. a Florida Corporation
D. Buyer: 465 Beach Avenue
Atlantic Beach, Florida 32233
Howard Fred Coble, Jr.
E. Seller:
F. Lender:
G. Pro 373 6th Street
may' Atlantic Beach, Duval County, Florida 32233 __
H. Settlement Agent: The Law Offices of Rod Schloth, P.A.
Place of Settlement: 2187 South Third Street, Jacksonville Beach, Florida 32250 Duval County
1. Settlement Date: August 30, 2011
J. Summary of Buyer's Transaction K. Summary of Seller's Transaction
100. Gross Amount Due From Buyer: 400. Gross Amount Due To Seller:
101. Contract Sales Price 365,000.00 401. Contract Sales Price 365,000.00
102. Personal Property 402. Personal Property
103. Settlement Charges to Buyer (line 1400) 18.50 , 403.
Adlustments for Items Paid by Seller in Advance: Adjustments for Items Paid by Seller in Advance:
106. City / Town Taxes 406. City / Town Taxes
107. County / Parish Taxes
407. County /Parish Taxes
108. Assessments 408. Assessments
1 Gross Amount Due from Buyer: 365,018.50 420. Gross Amount Due to Seller: 365,000.00
200. Amounts Paid by or in Behalf of Buyer. 500. Reductions in Amount Due to Seller:
201. Deposit / Earnest Money 10,000.00' 501. Excess Deposit (see instructions)
202. Principal Amount of New Loan 502. Settlement Charges to Seller (Line 1400) 12,272.00
203. Existing Loan(s) 503. Existing Loans)
204. 504. Payoff of First Mortgage to Bank of America 377,622.07
205. 505. Payoff of Second Mortgage to Regions 49,630.73
206. 506. Purchase Money Mortgage
Adjustments for Items Unpaid by Seller: Adlustments for Items Unpaid by Seller:
210. City / Town Taxes 10. City / Town Taxes
County / Parish Taxes Jan 1, 2011 thru Aug 29, ' County / Parish Taxes Jan 1, 2011 thru Aug 29, r'
2 11. 2011 5,011.76 11. 2011 5,0 t 1.76
212. Assessments ':512. Assessments
220. Total Paid by / for Buyer: 15,011.76 520. Total Reductions in Amount Due Seller: 444,536.56
300. Cash at Settlement from / to Buyer: 600. Cash at Settlement to / from Seller:
301. Gross Amount due from Buyer (line 120) 365,018.50 601. Gross Amount due to Seller (line 420) 365,000.00
302. Less Amount Paid by /for Buyer (line 220) - 15,011.76 602. Less Reductions Amount due Seller (line 520) 444,536.56
303. Cash From Buyer: $350,006.74 603. Cash From Seller: $79,536.56 j
1 have carefully reviewed the HUD -1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements
made on my account or by me in this transaction. 1 further certify that 1 have received a copy of HUD-1 Settlement Statement.
Lindley Tolbert Design, Inc.
Buyer: -- - - -- Seller: -
Lindley Tolbert, President Howard Fred Coble, Jr,
The HUD -I Settlement Statement which 1 have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in
accordance with thus statement.
Settlement Agent: Date: August 30, 2011
Rod Schloth
Settlement Date:August 30, 2011 File Number: RS11 -213
L. Settlement Charges
700. Total Sales / Broker's Commission: Paid from Paid from
Based on Price $365,000.00 @ 2.00% _ 57,300.00 Buyer's Seller's
Division of Commission as follows _ Funds at Funds at
701. 7300.00 to Watson Reaj_Corp. Settlement Settlement
702.
703. Commission Paid at Settlement 7,300.00
800. Items Payable in Connection with Loan:
801. Loan Origination Fee
802. Loan Discount
803. Appraisal Fee
804. Credit Report 805. Lender's Inspection Fee _ 806. Mortgage Insurance Application Fee
807. Assumption Fee
900. Items Required by Lender to be Paid in Advance:
901. Daily interest charge from Aug 30, 2011
902. Mortgage Insurance Premium
903. Hazard Insurance Premium (Supplied By Buyer POC)
904. Flood Insurance Premium
1000. Reserves Deposited with Lender:
1001. Hazard Insurance
1002. Mortgage Insurance
1003. City Property Taxes - -
1004. County Property Taxes
1005. Annual Assessments
1100. Title Charges: 1101. Settlement or Closing Fee to The Law Offices of Rod Schloth, P.A. ..__ 450.00
1102. Abstract or Title Search
1103. Title Examination
1104. Title Insurance Binder
1105. Document Preparation
1106. Notary Fees
1107 Attorney Fees
(includes above item numbers: _,.
1108 Title Insurance to The Law Offices of Rod Schloth, P.A. 1,900.00
(includes above item numbers :__._.__.....___--- . - -.__
1109 Lender's 0.00
Coverage . _
1110 Owner's 365,000.00 Risk Rate Premium: $1,900.00
Coverage - _
1200. Government Recording and Transfer Charges:
1201. Recording Fees: Decd 18.50 Mortgage 0.00 Releases 57.00 18.50 57.00
1202. City /County Tax/Stamps: Deed 0.00 Mortgage 0.00
1203. State Tax/Stamps: Deed 2,555.00 Mortgage 0.00 2,555.00
1204. Intangible Tax to Clerk of the Circuit Court
1205. .
1300. Additional Settlement Charges: -• - 1205. ...._._._
1300.
1301. Survey (Copy Supplied by Seller N /C1
1302. Pest Inspection
1303. Reimburse Beach Letter to The Law Offices of Rod Schloth. P.A. 10.00
1400. Total Settlement Charges (Enter on line 103, Section J and line 502, Section K) $18.50 $12,272.00
Buyer Initials: Lindley Tolbert
Seller Initials Howard Fred Coble, Jr,
1.-- 41.1f City of Atlantic Beach APPLICATION NUMBER
� r Building Department (To be assigned by the Building Department.)
800 Seminole Road � /
Atlantic Beach, Florida 32233 -5445 -(•
Phone (904) 247 -5826 • Fax (904) 247 -5845
•` *-011 ) V E -mail: building- dept @coab.us Date routed: _IA/a_
City web -site: http: / /www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: oL / 6/7/ Agie71-- ment review required Yes/ No
Building i/
Applicant: 7•2 ol9 Planning & Zoning
Tree Administrator
Project: . 1116
6 / Zig " � ` y 4-19 /) Public Works
Public Utilities
k-i-chi--7-) 9// / v Public Safety
/ Fire Services
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: proved. ❑Denied.
(Circle one.) Comments:
BUILDIN
PLANNING &ZONING Reviewed by: /71 t Date: 7 //
TREE ADMIN. Second Review: ['Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
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`' i St CITY OF ATLANTIC BEACH
J A ) 800 SEMINOLE ROAD
",- Zf ATLANTIC BEACH, FL 32233
` INSPECTION PHONE LINE 247 -5814
Application Number 11- 00002569 Date 9/14/11
Property Address 373 6TH ST
Application type description RESIDENTIAL OTHER
Property Zoning TO BE UPDATED
Application valuation . . . 15000
Application desc
REMODEL BATH AND KITCHEN
Owner Contractor
LINDLEY TOLERT DESIGNS GENESIS BUILDING CORP
465 BEACH AVENUE 2158 MAYPORT RD.
ATLANTIC BEACH FL 32233 ATLANTIC BEACH FL 32233
(904) 241 -0320
Permit PLUMBING PERMIT
Additional desc .
Sub Contractor . COGBURN AND WAKEFIELD PLBG
Permit Fee . . . 153.00 Plan Check Fee .00
Issue Date Valuation 0
Expiration Date . . 3/12/12
Special Notes and Comments
*2007 FLORIDA BUILDING CODE W/2009 REVISIONS
NATIONA1 ELECTRIC CODE
*REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING
DEPARTMENT IMMEDIATELY.
Other Fees STATE PLBG DCA SURCHARGE 2.30
STATE PLBG DBPR SURCHARGE 2.30
Fee summary Charged Paid Credited Due
Permit Fee Total 153.00 153.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.60 4.60 .00 .00
Grand Total 157.60 157.60 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
PLUMBING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233
Ph (904) 247- 5 Fax (904) 247 -5845
JOB ADDRESS: 3 7 3 6 4-4 S 1�(..¢.e,,T PERMIT # `/- 2 9
NEW OR REPLACEMENT INSTALLATION: Project Value $ Z-5-62)* 00
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer I Shower 1
Dishwasher I Shower Pan 1
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs 1 Urinal
Kitchen Sink _ Vacuum Breakers
Laundry Tray i Water Connected Appliances 1
Lavatory 3 Water Heater ___L—
Other Fixtures Water Treating System
RE -PIPE:
0
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater
Other Fixtures Water Treating System
MISCELLANEOUS:
❑ Sewer Replacement ❑ Back Flow Preventer ❑ Grease Interceptor (Trap) gallons (Requires 3 sets of plans)
❑ Lawn Sprinkler System - Number of Heads ❑ Well * *
** SJRWD Well Completion Form. Completed form to be submitted to the Building Department for final inspection. **
❑ Other
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have read
this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified
or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction.
Property Owners Name Z- tNQ (e (6 e--1- Phone Number 3v - 7 r
Plumbing Company CijeL.)r� A,0( (N.4-4 -e g t ci ?I.,44 ffice Phone 9 6 Y— 5 /2ff'a 9OV 3 79 -
Co. Address: S / vo j k. ` ' S t a SA-A' Z 32 t fr t ?Vit J4e.4 t�
I � Y Nom, �� State FL Zip 3 Z- '? y
License Holder (Print): / State Certification/Registration # CF i y2 9 Yo
Notarized Si' nature o Lic/se HI I •
I.
DEBO' ' Y ' ANDA WHITE • .. Ai
• My coM ssloN a EE o5�a . I rn and subscribed bef e this (9a of ./ 20
I ," `� EXPIRES: May 21, 2015
Ain i , Bonded Thtu Notary Publ Underw • 1 I ature of Notary Pub ,
A �
M = N 4 SA CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
y ATLANTIC BEACH, FL 32233
t J 3 f , INSPECTION PHONE LINE 247 -5814
Application Number
Property Address 11- 00002569 Date 9/21/11
Application type description RESIDENTIAL OTHER
Property Zoning TO BE UPDATED
Application valuation . . . 15000
Application desc
REMODEL BATH AND KITCHEN
Owner Contractor
LINDLEY TOLERT DESIGNS GENESIS BUILDING CORP
465 BEACH AVENUE 2158 MAYPORT RD.
ATLANTIC BEACH FL 32233 ATLANTIC BEACH
FL 32233
(904) 241 -0320
Permit ELECTRICAL PERMIT
Additional desc .
Sub Contractor . . LORE ELECTRICAL CONTRACTORS
Permit Fee . . . . 74.20 Plan Check Fee
Issue Date 00
Expiration Date Valuation . . . . 0
3/19/12
Special Notes and Comments
*2007 FLORIDA BUILDING CODE W/2009 REVISIONS
NATIONA1 ELECTRIC CODE
*REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING
DEPARTMENT IMMEDIATELY.
Other Fees STATE ELEC DCA SURCHARGE 2.00
STATE ELEC DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 74.20 74.20 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 78.20 78.20 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
ELECTRICAL PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd, Atlantic Beach, FL 32233
Ph 247 -5826 Fax (904) 247 -5845
JOB ADDRESS: ? 73 A s • PERMIT # // ` 2c6
JEA INFORMATION REQUIRED ON ALL PERMITS ( /5 AMPS 4 VOLTS / PHASE
VALUE OF WORK $ 0 ,_5 e c
NEW SERVICE n Overhead El
❑Residential (Main) Service Underground nT Underground up Pole
❑0 - 100 amps ❑ 101- 150amps ❑ 151- 200amps ❑ amps
❑ Commercial (Main) Service p # of Meters
El 0 amps ❑ 101- 150amps ❑ 151 -200am s
Conductor Type Size p J amps ❑ CT Service amps
❑Multi- Family (Main) Service
00 -100 amps ❑ 101- 150amps ❑ 151- 200amps ❑ amps # of Unit Meters
[II Temporary Pole ❑ amps
SERVICE UPGRADE
amps ❑ CT Service amps
NEW FEEDER (ADDITIONS, ACCESSORY STRUCTURES, ETC.)
❑ 100 amps ❑ 150amps 0200amps ❑ amps p ICT Service amps
ADDITIONS, REMODELS, REPAIRS, BUILD -OUTS, ACCESSORY STRUCTURES, ETC.
Outlets /Switches: 2 8' 0- 30amps 31 -100am s
Appliances: 0 -30am s p 101- 200amps
p 31- 100amps 101- 200amps
A/C Circuits:
0- 60amps 61- 100amps
Heat Circuits: # circuits @ kw
Number of Lighting Outlets, Including Fixtures:
OTHER ELECTRICAL PROJECTS
❑ Swimming Pool ❑ Sign ❑ Smoke Detectors Qty ❑ Transformers
KVA ❑ Motors hp
FIRE ALARM SYSTEM (Requires 3 sets of plans & Fire Alarm Checklist)
Qty volts /amps
VALUE OF WORK $
REPAIRS/MISCELLANEOUS
❑ Replace Burnt/Damaged Meter Can II Safety Inspection Canel Change ❑ OH to UG
LOther: ,41.41.4_ .(!
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have
read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether
specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of
construction.
Property Owners Name LYeaf 73 l �l—yLF , Phone Number
Electrical Company _ � / an l f�
P y -Ofl G �G�Ti2 /c /I 1 aidi. , G Office Phone 22.-//512 Fax
Co. Address: 2/Q /`� ���� City p(J
/ State �� Zip 3
License Holder ' t • ,
r � / : . e Certification/Re istration # C ?0 3d26 m sj-HRLEY L GRAHAM V' trallpar Notarized St , " of� �i A g
- i .rte`.. o EXPIRES: February 14, 2014
� ihi:/p" bonded Thor Notary , er
Public wr�e��
_-- _ % nd subscribed befo 4g thi. 1 i :. •t 20 11
Signature of Notary Pub 'c ,� ,, iar
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