REV-16-2196 r
Miami Shores Village ��'
Building Department UG 0 4 `Jlo
10050 N.E.2nd Avenue,Miami Shores,Florida 331.38 BY'
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949
_44-
FBC 20 C4
BUILDING Permit No. 11z C r/S` / 0 313
PERMIT APPLICATION Master Permit No. 2-
Permit
Permit Type:Electrical
JOB ADDRESS: 3'b ',� Cjz 57gf_�1�
City: Miami Shores County: Miami Dade Zip: �3 i
Folio/Parcel#: II -3 -7 06 (, 3 7 6 v
Is the Building Historically Designated: Yes NO !� Flood Zone:
OWNER:Name(Fee Simple Titleholder): IV WN C04)4 Al/k Phone#: '30
Address: _;S1; N�_ °( L ST►z+_7f5_ 33/3f)City: r"l/rte l $f-ba46,�l State: r� OA- Zip: 3 3 l 3 f
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: L on q nq 1 PzjiL C- Phone#: .3o5--73g
Address:�5 -/V C to ->/-
City: Cts^j^ / State: Zip: 33)6 ';;z,Qualifier Name: o v 1/ r! 9�,?,,�� L-Un j M�r� Phone#: �1,
State Certification or Registration#:- 1--C 13 lw 3 7 ) 3 Certificate of Competency#:
Contact Phone#:305-7 5S - )0,1/ Email Address: L O/1 Q/1 GC,/`-G O_ Q e,
DESIGNER• chitec ngineer: KA A7U C4A V-4 P6 C Phone#: 3 PS '73-V• 2�l
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: i�Q/C/Y� LA-�iaJr
Submittal Fee$ Permit Fee$ `Tf i�40,e- CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ • 0
1
"11.
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 will 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 w ich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be coved and a sion fee will be charged.
Signature Signature
er or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20& ,by P6'VS C C�AAiA3 C7 L L day of f" ,20 A-,by M l�qG) Lin 1
who is personally known to me or who has produced who i ersonally known to me or who has produced
�— • L As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
\\:V\
Sign: Sign:
Print: "- Print: e Z
'M%'%i', CHASE CAMPBELL
My Commission Expires: .••., MY COMMISSION M FF 200055 My Commission t
ublic State of Florid&
EXPIRES:February17,2019 th, e
' RF;Rr 8ondedThruNdaryPubliclNidenn4era mPssionZFF000321
j :( M:
p410Bt2017
APPROVED BY �^ Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)