PW-17-565Miami 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) 762-4929
FBC 20 14'
BUILDING Master Permit No. ` vv n-565
PERMIT APPLICATION Sub Permit No.
❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING ❑ MECHANICAL •PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1200 NE 91st TER.
City:
Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO X
Occupancy Type:
Load: Construction Type: Flood Zone: BFE:
FFE:
OWNER: Name (Fee Simple Titleholder): RIGHT OF WAY Phone#:
Address:
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: TECO PEOPLES GAS Phone#: 954-453-0806
Address: 5101 NW 21 AVE. STE. 460
City: FT. LAUDERDALE State: FL _N. Zip: 33309
Qualifier Name: JESUS VEGA ! 954-453-0806
.hone#:
E 1608 1 e 4—,.., :
State Certification or Registration #: Ce ificate-of Cor7�npetency
DESIGNER: Architect/Engineer: `,�_-_Phone#:
Address: City:ate:ifil
Value of Work for this Permit: $ 1000
Type of Work: ❑ Addition ❑ Alteration
Square/Linear Footage of.11)
❑■ New
❑ Repair/Replace \ ❑ De olition
Description of Work: PERMIT TO INSTALL A NEW GAS SERVICE LINE
Specify color of color thru tile:
Submittal Fee $ 5V P'` I Permit Fee $ iC17 ' CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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
OWNER or AGENT
CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of , 20 , by / day of fb4 , 20 / 7 , by
who is personally known to �S ti%Es 4 , who is personally known to
me or who has produced as me or who has • oduced
as
identification and who did take an oath. identificati n and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
Print: rt,.
Seal:
.X; ,,, HUBErci NUNtL
<P ° Notary Public - State of Florida
•_ My Comm. Expires Sep 11, 2017
Commission # FF 043679
' % ;n os Bonded Through National Notary Assn. Ef
*************************************************************v*�•►st�a*,v arrau;sus€*:*'**—*—vi r*T**Y***********
APPROVED BY
R
3-4-t Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)