PW-16-3429BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department /tell
RECEIVED
DEC 21.2016
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 201+
Master Permit No. QW t 2"' 1 b- 34 21
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL •PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores
4--#4A-1° l'c.cI Ga te— R--
City:
2
County:
Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
RIGHT OF WAY
OWNER: Name (Fee Simple Titleholder): Phone#:
Address:
City:
Tenant/Lessee Name:
Email:
/State
Phone#:
Zip:
!; !y,
rr,
CONTRACTOR: Company Name: TECO PEOPLES GAS' 4' t•ne#: 954-453-0806
Address:
5101 NW 21 AVE. STE. 4604,1V !
P.
.y
City: FT. LAUDERDALE State: FL Zip: 33309
Qualifier Name: JESUS VEGAh�#: 954-453-0806
o
State Certification or Registration #: E1608 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 1000
Type of Work: ❑ Addition ❑ Alteration
Square/Linear Footage of Work:
❑ New
❑ Repair/Replace ❑ Demolition
Description of Work: PERMIT RE -NEW FOR A GAS SERVICE LINE
Specify color of color thru tile:
Submittal Fee $ 1 Permit Fee $ /c0 CCF $ 0 • 6C) CO/CC $ 575
Scanning Fee $ 3 • Radon Fee $ a' DBPR $ a. J Notary $
Technology Fee $ v -Training/Education Fee $ 6 ' 20 Double Fee $
Structural Reviews $
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE$ 1 CPI 10
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 3.0'› v '�
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me
day of , 20 by day of
, who is personally known to
me or who has produced as me or wh
identification and who did take an oath. identifi
NOTARY PUBLIC: NOTA
is personally known to
Sign:
Print:
Seal:
Seal:
*************************** *****************************sss***************************************
APPROVED BY 2 Plans Examiner
(Revised02/24/2014)
Structural Review
Zoning
Clerk