Application for Plan Revision — Sen. Val. D. Esteban, Master Permit Number 2005-030767

MIAMI-DADE COUNTY BUILDING DEPARTMENT 11005 S.W. 26 St., Miami, FL 33175-5874 www.co.miami-dade.fl.us APPLICATION FOR PLAN REVISION ***IF YOU DO NOT WISH TO RECEIVE INFORMATION REGARDING THIS APPLICATION, YOU MUST INDICATE THIS ON THIS FORM.*** ***PLEASE FILL OUT COMPLETELY*** Master Permit Number C18005069818 Job Address 2005 80th Ter Owner's Name Jose A. Martinez Owner's Address 2005 80th Ter City Hialeah State FL Zip Code Contractor's Number Contractor's Name Jay Davis Qualifier's Name Jay Davis Owner's Name Sam Val. Owner's Address 2005 80th Ter City Hialeah State FL Zip Code Comments I certify that the work to be performed is described below. I certify that all information is accurate. I understand that any false statement made in this application will be considered perjury and may subject me to criminal prosecution. I further certify that I am a licensed architect, engineer, or contractor, and that I will be responsible for the work described herein. I understand that any false statement made in this application will be considered perjury and may subject me to criminal prosecution. (Check all that apply) In this revision to a roofing, siding, window or door change permit: If yes, please check here: [ ] (Note to staff if box above is checked use "A" instead of "R" for revision type) [ ] Roofing [ ] Siding [ ] Windows [ ] Doors [ ] Electrical [ ] Plumbing [ ] Mechanical [ ] HVAC [ ] Pool/Spa [ ] Pool/Deck [ ] Fence/Gate [ ] Zoning [ ] Addition to Structure [ ] Department of Environmental Resources Management (ERM) Signature of Owner or Owner's Agent Print Name Date STATE OF FLORIDA, COUNTY OF MIAMI-DADE Sworn to and subscribed before me this ___ day of __________, 20__ (SEALED) Personally known or Produced Identification Type of Identification Produced NOTARY PUBLIC My Commission Expires Signature of Notary Public Printed Name State of Florida 36