PW-17-319BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC
PLUMBING ❑ MECHANICAL
JOB ADDRESS: 241 NW 91 ST.
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
RECEIVED
FEB 0 7 2017
FBC 201'1
Master Permit No.1W 11 31 cl
Sub Permit No.
❑ ROOFING ❑ REVISION
PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load: Construction Type:
County: Miami Dade
Flood Zone: BFE:
NO X
FFE:
OWNER: Name (Fee Simple Titleholder): RIGHT OF WAY Phone#:
Address:
City:
Tenant/Lessee Name: Phone#:
Email:
State: Zip:
CONTRACTOR: Company Name: TECO PEOPLES G
Address: 5101 NW 21 AVE. STE. 460
Phone#: 954-453-0806
City: FT. LAUDERDALE
Qualifier Name: JESUS VEGA
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Address:
Sta
FL ''+ Zip: 33309
,.\ Phone#: 954-453-0806
E1608A>�',
rtif fcate of1Cor"`►i petency #:
N.
\r1, , ,. P one#:
City: 6Ste: Zip:
Square/Linear Footage of Work:
Value of Work for this Permit: $ 1000
Type of Work: ❑ Addition ❑ Alteration New ❑Repair eplace n Demolition
Description of Work: PERMIT TO INSTALL A NEW GAS SERVICE LINE
Specify color of color thru tile:
Submittal Fee $050• b Permit Fee $I,�� '� CCF $ ' COO CO/CC $
Scanning Fee $ � Radon Fee $ 2 2 S DBPR $ 2'. • 2 Notary $
C
Technology Fee $ ' G O Training/Education Fee $ ' Z=C.) Double Fee $
Structural Reviews $ Bond $
(Revised02/24/2014)
' 0 .
TOTAL FEE NOW DUE $ / IS.
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 '3C0c
`�
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of , 20 , by 4. day of r.41-4 , 20 / 7 , by
0
, who is personally known to
me or who has produced as me or who hasp • i -d as
identification and who did take an oath.
NOTARY PUBLIC:
identification .nd who did ak ao
NOTARY PU
Sign: Sign:
Print: Print:
Seal: Seal:
HUBERT NUNEZ
Notary Public - State of Florida
My Comm. Expires Sep 11, 2017
Commission # FF 043679
As' Bonded Through National Notary Assn.
************************************************************************************************************
APPROVED BY 17 Plans Examiner Zoning
(Revised02/24/2014)
Structural Review
Clerk