REV-16-2926 Miami Shores Village RCC~`*. Fa
Buildin g Department artment R E C vP
. 6
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 DCT(%%
Tel: (305)795.2204 Fax: (305)756.8972
INSPECT HONE NUMBER: (305)762.4949
FBC 20 lLI
BUILDING 4 • ' ; r' 2 15 -3 21
PERMIT APPLICATION er
Permit Type: Electrical CSU 1 S 1 OWN)
JOB ADDRESS: I Sot Nyfwy)o re W
City: Miami Shores L County: Miami Dade Zip:
Folio/Parcel#: 11 — ��i -0J
0 5 21 � 0 �-'2
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): S Q n yr Nl Slam' Phone#:-M 3S0 pb I c,
Address: Cl 3 01 11_1 re,
City: M'�WA. W ��� State: f�L' Zip: 3513&
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name:TI/.J'a' 0'2'C ✓)G J:n<:�_ Phone#:
Address:,,,,,4 9�
City:U-n Q qy on& State: � Zip:330'z_1
Qualifier Name: Ligon (c,oZja,f) Phone#:
State Certification or Registration#: F—e. I bOnSb-70- Certificate of Competency#:
Contact Phone#:LA6S 3306'0D Email Address:�U`.�Ci�IQl�Y1G?OlCor.J1C.�1� CJfy�k
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit:$ 9500 Square/Linear Footage of Work:
Type of Work: ❑Address Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: ULJ 1 5;()^ :bo i Q,C K rCj Pe (_ PV_X�
Submittal Fee$ Permit Fee$ ki CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
A, 4
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 which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be app r d a reinspectio ee will be charged.
Signature .J Signature
er or Agent Contractor
The foregoing instrument was acknowledged before me this 2-0 The foregoing instrument was acknowledged before me this G
day of 0 20��by Uq LV(I J.S�6 day of o ov�oe r,20 by I P-0 V7 �Pb Z�qN1
who is personally known to me or who has produced0114 who ispersonallyknown to me or who has produceda^�(
SAO k)0- As identification and who did take an oath. C�W/r as identification and who did take an oath. V
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: (( Sign: il
Print: G J► Print: �^ St.
M Commission Expires: �`...... ANA LUCiASIERRA
My Commission Expires: `•Y�i ANALUCIASIERRA y p „4 &;: MY COMMISSION#FF 224104
MY COMMISSION#FF 224104 EXPIRES:April 23,2019
I23�1 a' EXPIRES:April 23,2019 P
Bonded Thru Notary Public Underwriters A,,,,,\••` Bonded Thru Notary Public UrMerxa ters
APPROVED BY Z��"G�I.P Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)