REV-19-1729 (2)BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
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
❑ ROOFING
❑■ PLUMBING ❑ MECHANICAL [:]PUBLICWORKS
FBC 20
Master Permit No. PL-0i5-,19-993
Sub Permit No. k V —07-) I "'�2�
M REVISION ❑ EXTENSION [—]RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOBADDRESS: 79 NE 91ST ST, MIAMI SHORES, FL 33138
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: d — 32 06 — 013 — 0 /3 0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: � Name (Fee Simple Titleholder): ROBBIE SINGER Phone#:
Address: / `7 �F / * S�%ee, YL
City: Hiarol Shores State: F-lin 1 Cl J (,, Zip: 3313 O p
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: SUBURBAN PROPANE
Address.. 3800 NW 59 ST
City: MIAMI State: FL
Qualifier Name: ALEX BRITO
State Certification or Registration #: LP01196
DESIGNER: Architect/Engineer:
Add
hone#: 305-635-4427
Zip: 33142
hone#: 305-635-4427
Certificate of Competency #:
hone#:
State: Zip:
0.0
Value of Work for this Permit: $ lcn Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New . ❑ Repair/Replace ❑ Demolition
Description of Work: SET TANK ONLY. GAS LINES INSTALLED UNDER Permit Number: PL-06-19-1471
L
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $
Permit Fee $ CCF $_
Radon Fee $ DBPR $
Training/Education Fee $
CO/CC $
Notary $
Double Fee $ _
Structural Reviews $
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $�
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
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 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 ab nce of such posted notice, the
inspection will not be approved and a reinspection fee will be charged. ---7
Signature &I
OWNER or AGENT
The foregoing instrument was acknowledged before qme this
t2 ce day of '/20 ( by
,Q�B[3/C S/ter" who is pers� to
me or who has produced 1,,Vlaey'S L/•C as
identification and who did take an oath.
NOTARY
Sign:
Print:
,'---ueDra
Seal: '?• �<'
Sinydei
COMMISSION ;FF916751
EXPIRES: September 9.2019
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www.AARONNOTARY,COM
Signatu
CONTRACTOR
The foregoing instrument was acknowledged before me this
23 day of w L- 20 ii by
wh is personally known td
me or who has produced
identification and
NOTARY P
Sign:
Print:
Seal:
as
o did to
REK
tate of Florid
jon GG 129054
021
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APPROVED BY 4!12�4�9 Plans Examiner
Zoning
Structural Review
(Revised02/24/2014)
Clerk