APP-R-24-217388WY ®E ®ELAA4 ®EACH ROOF / RE-ROOF PERMIT APPLICATION
100 NW 1`s Avenue Delray -Beach FL 33444
(561) 243-7200 Fax: (561) 243-7221
Website: mvdelraybeaclt.corn
PROPERTY CONTROL #. 62 - e/a _4',G _ate. o9. e722. CA3o
PLEASE PRINT
/~ JOB SITE ADDRESS $(/ /a ~)~T(~/i7 ! c f'z.,
PROPERTY OWNER NAME t '
HOME PHONE( ') CELL
PROPERTY OWNER ADDRESS
''//ROOF CONT'R(COMPANYjNAMES8eOSy >~F~'Gih5 Gt7-
R00FC NT'RADDRESS ^ 10 SE 2t2d
CITY. Qt/ /Z q ' Q ST 1 G ZIP/ 334/23
BUS.PHONE( (~J( ) 2 74'3g;2D CELL -qS//o7r L
FAX E-MAIL (an {rtcr{fi b!vC/s 20D.cn/S ' r~
(ew2/c tri//e{
FOR OFFICE USE ONLY:
BLDG PERMIT.!):
ROOF PERMIT #:
PERMIT FEE:
PLAN CHECK FEE:
MCR #:
***************r*******w********
APPROVALS:
PLAN: DATE:
P & Z: DATE:
NOTE: PERMIT EXPIRES IF WORK /S NOT STARTED WITHIN 180-DAYS OR IF ACTIVITY LAPSES FOR 180 DAYS. PLANS MUST BE
ON THE JOB SITE FOR ALL INSPECTIONS. FINAL INSPECTION IS REQUIRED ON ALL PERMITS.
PROJECT COST (Labor and Material) S '/ o~6Z2
Check one: _NEW CONSTRUCTION _RECOVGROVER EXISTING 'REMOVE EXISTING & REPLACE _R/R A/C UNITS
/
(Engineer's Letter Rcqulrcd) , + (Meclt. Permit Required)
Check one: SINGLE-FAMILY* MULTI-FAMILY COMMERCIAL
*MITIGATION REQUIREMENTS IF SINGLE FAMILY:
1. YEAR BUILT (cisecic one) _' BEEFORE MARCH 2002 (Go To #2) AFTER MARCH 2002
2. HOUSE VALUE: s 63 7 , r da MUST PROVIDE: HOME INSURANCE SUMMARY SHEET OR
(IF $300,000, OR MORE, NOT INCLUDING LANb VALUE, COPY OF MOST RECENT TAX BILL OR
GO TO #3) PROPERTY APPRAISER OFFICE W EBPAGE
3. SUBMIT RE-ROOFING MITIGATION DOCUMENT PACKAGE and BUILDING APPLICATION
TYPE/COLOR OF ROOFiMATERIAL REMOVED 'Tm t-F TYPE/COLOR OF ROOF MATERIAL INSTALLED x m -t'
NOTE: FOLLOW MANUFACTURER'S GUIDELINES AND NOTICE OF ACCEPTANCE FOR SHINGLE INSTALLATION.
ROOF TYPE (CIRCLE): MANUFACTURER: PRODUCT APPROVAL NUMBER:
I'LAr
SLOPED ~xrrmu Ft 25&c / ,O —E 4L
%'c Os go?? 0.23 o,3Ve6 OR
SIGNATURE ¢'F QUALIFIER CONTR. REGISTRATION!) WORKERS COMP#
STATE OF
COUNTY OF 7'-7C4 L4 t e&c7q
ow]edged before me this day
Y
The foregoing instrument was ac
of ''4- 20~224L (
otaryPu• ie
MARIA TAIN
Notary Pi:.Iz - St :e :' °foriea
Commissicn q -i-' =':1L9!
My Comm. Expires Acg J, 2027
— Bonded through National Notary Assn.
EXEMPTS (FID /FEIN) #
Personally Known
OR
Produced Identification
Type of Identification Produced
(SEAL)
Rvsd. 3/I