PL-07-2198Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDINGR i.G., E Permit No. ?t --I - ` w
PERMIT APPLICATION I
aster Permit No. ' ,l. q
FBC 2004 OCT 2 92007
Permit Type: Plumbing
BY:=L2
Owner's Name (Fee Simple Titleholder) "`t C 1kf ` C 0Q Y" Phone #'? Qs- n a-6 — 13Z Q
Owner's Address5_3 ( 3 W 013 76 '
City I" - S6,reS State V L Zip .33 1 50
Tenant/Lessee Name
E-MAIL:
Phone #
Job Address (where the work is being done) 53 )One Cha 31 ma
City Miami Shores Village County Miami -Dade Zip, 150
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company Name T Phone #
Contractor's Address
v _
va
City
Qualifier Name
State Certificate or Registration No.
E-MAIL:
Zip
Phone #
Certificate of Competency No.
Architect/Engineer's Name (if applicable) 7N& CG,aLk o LL( Phone # M- 1:54— IA -)4
Value of Work For this Permit $ 4 517 o .00 Square / Linear Footage Of Work:
Type of Work: Addition Alteration ErNew
N
ElRepair/(Rye place El Demolition
Describe Work: NfC tce h S,•i 1 ayr+ l nq -p , ( tt(rGf' 0 r 11 C7
in 15;x- 6 n. N P_ w ct r. `
Submittal Fee $ Permit Fee $ /' CCF $ CO/CC
Notary $ Training/Education Fee $
Scanning $
Bond $
Structural Review. $
Radon $
Code Enforcement $
Technology Fee $
DPBR $ Zoning $
Double Fee $
Total Fee Now Due $
See Reverse side ->
Bonding Company's Name (if applicable)
Bonding Company's Address
City S tate
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State
Zip
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 regulatingconstructioninthisjurisdiction. 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 allapplicablelawsregulatingconstructionandzoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOURPAYINGTWICEFORIMPROVEMENTSTOYOURPROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OFCOMMENCEMENT."
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 siteforthefirstinspectionwhichoccursseven (7) days after the building permit is issued. In the absence of such posted notice, theinspectionwillnotbeapprovedandareinspection, fee will be charged.
0Signature `—• — Signature
Owner or Agent /
The foregoing instrument was acknowledged before me this d—/
day of b`(JT—, 20 D7 / by l"L IC44A -RL
who is personally known to me or who has produced -4—
As identification and who did take an oath.
NOTARY PUBLIC:
Contractor
The foregoing -instrument was acknowledged before me this
day of , 20 _, by
who is personally known to me or who has produced
as identification and who did take an oath.
C
Sign: 5" C ' L. Go!uniayl{..
Print: 'OCCT.mission #DD444SE
2GSBin& 1 tlru Atlantic bozu,. ' In, My Commission Expires: '
APPLICATION APPROVED BY:
Revised 02/08/06)
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
9//dans Examiner
Engineer
Zoning