Building Permit Application — Jay Vie LLC, Master Permit 2005-000-767 (2005)

MIAMI-DADE COUNTY BUILDING DEPARTMENT 11805 S.W. 26 St., Miami, FL 33175-2474 1200-003 (Single Family or Duplex) (Rev. 01/01) Lot 4 C-2005-065-915 A-101-1020 (100 Ft. In Depth) ***THIS FORM IS NOT VALID UNLESS THE DEPARTMENT HAS RECORDED THIS APPLICATION IN THE OFFICIAL RECORDS.*** ***PLEASE DO NOT COMMENTARY*** Master Parcel Number: 2005-000-747 Job Address: 1606 33rd St. Contractor's Number: CGL003152 Contractor's Name: CGL CONTRACTORS Qualifier's Name: JEFF REYES Owner's Name: J & M LLC Contact Name: Amy Vazquez Date: 2/09/05 Description of Work: Roofing Residential (Single Family or Duplex) [x] Commercial [ ] Application is hereby made for plan revision as indicated below. I certify that all information is correct, and understand that plans will not be reviewed until all required fees are paid. I further understand that this application does not relieve the applicant from the responsibility of complying with all applicable laws, rules, and regulations in back of legislation. I also agree that any error in indicating the plan(s) required may result in the need for further plan revisions or inspection delay. The plan revision affects the following disciplines. (Check all that apply) Is this a revision to a roofing, electrical, plumbing, fire, or alarm, life safety, or fire suppression permit? If yes, please indicate the permit number and type of permit for revision type** If this is a revision to a building, electrical, plumbing, fire, or alarm, life safety, or fire suppression permit** [ ] Building [ ] Roofing [ ] Plumbing [ ] Sign [ ] Zoning [ ] Electrical [ ] Mechanical [ ] Private Works/Conservancy [ ] Sign [ ] Fire [ ] Planning [ ] Public Works [ ] Structural Residential or Small (See South Florida Building Code, Permit Only) Department of Environmental Resources Management (Drain) Signature of License or Owner Agent: [Signature] Print Name: BLANCO VEGA STATE OF FLORIDA, COUNTY OF MIAMI-DADE Sworn to and subscribed before me this 9th day of February, 2005 (SEAL) Notary Public Name: [Signature] Type of Identification Produced: [illegible] Signature: [Signature] Print Name: Amy P. Vazquez STATE OF FLORIDA, COUNTY OF MIAMI-DADE Sworn to and subscribed before me this 9th day of February, 2005 (SEAL) Notary Public Name: [Signature] Type of Identification Produced: [illegible] 4