REV-19-2489 (2)BUILDING
PERMIT APPLICATION
Miami Shores Village RECE ED
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 20
Master Permit No. ELC-08-19-1805
Sub Permit No. C,) ey `
❑BUILDING ffil ELECTRIC ❑ ROOFING 0 REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: 180 NE 99TH STREET
CANCELLATION ❑ SHOP
DRAWINGS
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): MIAMI SHORES CENTER LLC Phone#: (305) 864-8885
Address:210 71 ST STREET SUITE 309
City: MIAMI BEACH State: FL Zip: 33141
Tenant/Lessee Name: DR THROWERS SKIN CARE Phone#:(305) 757-9267
Email: orit@elyseeinc.com
CONTRACTOR: Company Name: BALLAD ELECTRIC INC Phone#: (754) 400-8588
Address: 4725 MONROE ST
City: HOLLYWOOD state: FL Zip: 33021
Qualifier Name: NIGEL HENRY Phone#: (813)362-6161
State Certification or Registration M ER13015192 f 1(Q 6 dyMertCificate of Competency #:
DESIGNER: Architect/Engineer: E & K ENGINEERING Phone#: (786) 701-2049
Address:12001 SW 128 CT #207 City: MIAMI State: FL Zip: 33186
Value of work for this Permit: $ 3,800.00 Square/Linear Footage of work. 79
Type of Work: ❑ Addition ❑ Alteration ❑■ New ❑ Repair/Replace ❑ Demolition
Descriotion of work: NEW SERVICE AT 180 NE 99 ST PUMPS FOR SEWER CONNECTION,
change from underground new service to overhead new service, no change on value of work
Specify color of color thru tile:
Submittal Fee $� Permit Fee $ (�' CA CCF $ 2�'fQ CO/CC $ /-
Scanning Fee $ Radon Fee $ 2- �7 DBPR $ Z CA Notary $ Lz
Technology Fee $ &s Training/Education Fee $ G - ` Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ (3 3 • Q
(Revised02/24/2014)
4
Bonding Company's Name (if applicable) NA
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable) NA
Mortgage Lender's Address
City
State
Zip
ME
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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of _� 20 �, by
flkimN' who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
L
Sign:
Print: 04 1 Vk0,-L1�
Seal:
ta+�� ORITMIMOLIN
MY COMMISSION # GG 162406
EXPIRES: December 14, 2021
APPROVED BY
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of 20 , by
who is personally known to
me or who has produced b�'as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: -D I (V l p
SINDIA AL.VAREZ
Seal: _ MY C0I,1MISSiON # GG 238273
EXPIRES: September 3, 2022
"rF�F,Ft°P Rondad Thru Notary Public U denwitors
################################
s Examiner Zoning
(Revised02/24/2014)
Structural Review Clerk