PW-16-3426•
M
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BUILDING
PERMIT APPLICATION
❑ BUILDING
❑PLUMBING
JOB ADDRESS:
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2014
Master Permit No. ()V4 12 lb —34-Z6
Sub Permit No.
❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ MECHANICAL •PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
City: Miami Shores
County: Miami Dade
Zip:
Folio/Parcel#: the Building Historically Designated: Yes
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):
Address:
City:
Tenant/Lessee Name:
Email:
Construction
p
RIGHT OF • AY
Flood Zone: BFE:
Phone#:
NO X
FFE:
State:
Nr I
Zip:
Phone#:
CONTRACTOR: Company Name: TECO PEOPLES GAS Phone#: 954.453-0806
Address: 5101 NW 21 AVE. STE. 460
City: FT. LAUDERDALE State: FL
Qualifier Name: JESUS VEGA
State Certification or Registration #: E1608
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $ 1000
Zip: 33309
Phone#: 954-453-0806
Certificate of Competency #:
Phone#:
City: State: Zip:
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of work: PERMIT RE -NEW FOR A GAS SERVICE LINE
fia r-ep lac t PVA 6 - Ib - k391
n Demolition
Specify color of color thru tile:
Submittal Fee $ O paid Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ 'l
Structural Reviews $
(Revised02/24/2014)
1✓`'fCCF$ o.63
DBPR $ a. aS Notary $
Training/Education Fee $
0.76
Double Fee $
Bond $ 0
TOTAL FEE NOW DUE $ 1 1 5. '�
•
•
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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 approved and a reinspection fee will be charged.
Signature Signature '3'
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
The foregoing instrument was acknowledged before me this
day of , 20 , by Z-4 day of/J a .— "'a
who is personally known to iF4.� S Y >_y .•• S T•
me or who has produced as me • r o has produced 0 ,sLL
\(/'„,�' :Q lA. C
identification and who did take an oath. id ntificad on and who did take an oath. 1- N
acc _,-,cz
W V X O .
OD NOTARY PUBLIC: N'TA'Y ' BLIC: . ”' y B
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Sign:
Print:
Seal:
Sig
Print:
Seal:
*****************************w'*****************************************************************************
APPROVED BY /_ti %_ z..f—/k
(Revised02/24/2014)
Plans Examiner
Structural Review
Zoning
Clerk