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<br />.JURfSDICnON.OF' YOUR ~CBOICE. <br />. :.BlJDj~:DEF.AR!l'MEm <br />RE:Pcrmit~ 7iy..V 9/17107 <br /> <br />" <br /> <br />DtsDection AffidaVit. <br /> <br />.I Sc./r B{ 0 c' k~", <br />(pleae y.niIlt DIIIIle ad ciIcle lie. 'I)pe) <br /> <br />I . . . <br /> <br /> <br />~'..~~~ <br />! . 468 Bll,ldmg Inspector"" <br /> <br />Liceoae#.; (C.C OJ 7 ? (-, <br />On orabo~t 'i / /~. 3'. f:',o ():~'IIV\ . ,I did~yinspect'1:hf! 1'oof <br /> <br />declnwlmrrandlor se~Ondarv ~ barrier' work: at r~. sf <br />(ctrcle onI;) . (Jab SitB.AddnSs) . <br />. 7~~~'~r/is ;C./ <br />Based upon that e,YmninAtion I ha~ ~ed1he instB11ati~ was done acconting to the <br />BmricBDe Mi1igationR.~fit Manual (Based on 553.844 F.S.) <br />~.~ <br />/Sign,-ture . <br /> <br />~ <br /> <br />STATE OF FLORIDA . <br />COUNTY OF . Cl~ <br />Swam to and subscribed before me this lL. day. of <br />By &n~acJ M~ V\ :.' . <br />. - - " NG PnhIic, Stole ofFlorido. <br />Jj-U/Zwt.- ~. <br />. (Print. we or WImp name) <br /> <br /> <br />.200Z <br /> <br />N O""W',Asion.No.; <br />Pencma1ly JaJow!~ or <br />Prod;pccd Idcntific:aticm <br />Type ofi~caticm produced. <br /> <br />.. Ge:rItD1, BlIildiq. llaicladW; or llcxdiag CmdrKIDr br 11II)' iDdividaal ~..s 1IDdEr 468 P".S. 10 :mala:. &1Gb & <br />:iZlllpectiClll. lDc:1ude pIlatDJIIIPbs of ClICb p1ae oftheraafwilh the: pcIDIiH~ onddnss ~ c1esdy IbaWli JDIIIbd on tbe <br />dIICk mr IIlICh iDJpectiOJl. . <br /> <br />. CORI ANN KEOUGH.. ~ <br />NoeIry PuIIIc . SIIII of ~ <br />I. ~ CommlIIlal, ExpReAug t7, 1010 <br />l . If!. ~ CommlIIIo., . DO 588503 <br />... Bonded By N8tIoNII NoIllry A81n. <br />