FL-13-1927 Miami Shores Village _
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 AUG 13
2013
Tel:(305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
FBC 20
BUILDING Permit No. z_1A 3 f 19E`A--
PERMIT APPLICATION Master Permit No._rzc l3 — I
Permit Type: Electrical ChOCEUED
-1
JOB ADDRESS: Ez
City. Miami Shores County: Miami Dade Zip:_33(3 10
Folio/Parcel#: 12DC,7
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee
Simple Titleholder): —Tt,-A M � Phone#:_16U CL
U
Address: � 105 g4
City: 42 rM . State Zip:
Tenant/Lessee Name: Phone#:
Email: I
CONTRACTOR:Company Name: JO� ��� /��v i�C 4 1.�ic 1/e Phone#:
Address: ,/log _449 6;*
City: Nt 1,0 Gtr State: " Zip. s6 T
Qualifier Name: O O way&6 _ Phone#:
State Certification or Re 'stration#: Ce ficate of rCompetency#. /0 e6010 6(3
Contact Phone#: 006)9-�q`V itl Emai'_Address:"50 54 ��eG�N C e (.+V Z . c0)01
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ 1 JCO Square/Linear Footage of Work:
Type of Work: DAddress OAiteration ONew Repair/Replace ODemolition
Description of Work:
$J
'Sir/'A
Submittal Fee
Permit Fee$ CC x2-f�m�`' CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
!W"0
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
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. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and AIR CONDITIONERS,ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work wiH be done in compliance with all
applicable laws regulating construction and zoning.
"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."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be appro a reinspection fee will be charged.
Si
U Wtryp4 signature �� �`�
��•,,. .,. *�wner r Agent �— Contractor
omg
'ins ttum�—was ac kn me this o The foregoing instrument was acknowledged before me thisf d
di i by �,^'` day of 20 Z by 19LL*JD0
onna , to me or w has produced ho is personail own to me r who has produced
ion and who did take an oath. as identification and who did take an oath.
iZ ."•����
NO !"c7SLIC: NOTARY PUBLIC:
Sign: `' Sign:
Print: Print:
My Commission Expires: My Commission Expires: NWVIDAL
� r•u
to MY COMMSSION i EE 986653
* # EXP AES;January 21,2017
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012XRevised 07/10/07)(Revised 06/1012004)(Revised 3115/04)