PL-18-3108Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
issue Date:12/05/2018
Location Address Parcel Number
1090 NE 104TH ST, Miami Shores, FL 33138 1122320290190
Contacts
Permit NO.: PL-10-18-3108
Permit Type: Plumbing - Residential
Work Classification: Pool - Private
Permit Status: Approved
Expiration: 04/08/2019
ERIKA BATEY Owner
1090 104
VAN KIRK & SONS INC Contractor
ROBERT P VAN KIRK JR
3144 SW 13 DR, DEERFIELD BEACH, FL 33442
Business: 9547554402
Other:7863262747
Description: PIPING FOR POOL/SPA Valuation: $ 1,000.00 Inspection Requests:
305-762-4949
Total 5q Feet: 0.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$0.60
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.20
Plumbing - Pool - Residential
$100.00
Scanning Fee
$9.00
Technology Fee
$3.75
Total:
$167.55
Payments Date Paid
Amt Paid
Total Fees
$167.55
Check # 42919 10/09/2018
$50.00
Check # 43042 12/05/2018
$117.55
Amount Due:
$0.00
Building Department Copy
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I ertify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulaUp.iKonstruction Zoning. Futhermore, I authorize the above named contractor to do the work stated.
Leuthorized S�dnature: Owner4 / Applicant / Contractor / Agent Date
December 05, 2018 Page 2 of 2
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
ocr ep zqh�
i�
FBC 2011 bit
BUILDING Master Permit No. —31CA
PERMIT APPLICATION Sub Permit No. �L g -31 09
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑■ PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOBADDRESS: 1090 NE 104th Street
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:11-2232-029-0190 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Richard E Mellett J TRS & Erika Batey J TRS phone#:
e,,A--1090 NE 104th Street
City: Miami Shores
Tenant/Lessee Name:
Email
State: FI
Zip:
CONTRACTOR: Company Name: Van Kirk & Sons Inc. Phone#: 954-755-4402
Address: 3144 SW 13th Drive
city: Deerfield Beach State: Florida Zip: 33442
Qualifier Name: Robert P. Van Kirk Jr. Phone#: 954-755-4402
State Certification or Registration M CPC-0459�56 Certificate of Competency #:
hc9
DESIGNER: Architect/Engineer: 1)6ata 1'
,/y� C eSa-b Phone#:qs4-bqS- �LIy-3
Address: 0 1 G D NkAJ k � C4- ' City: S, n+► State: -t_ Zip: ?416:1,
Value of Work for this Permit: $ 11 d c) U Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration Ne ❑ Repair/Replace ❑ Demolition
a
Description of Work:
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ I k--1 • 55
(Revised02/24/2014)
Bonding Compainy's Name (if applicable) N/A
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 the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OWNER or AGEN CONT CTOR
The foregoing instrument was acknowledged before me this
1504 day of i 20 �� by
Richard E Mellett J TRS & Erika B tey J TRS
who is personally known to
me or who has produced GC U-g00-200 ZS=715�as
identification and who did take an oath.
NOTARY
FF 978854
The foregoing instr ment was acknowledged before me this
D-7 day of 20 (g by
411n ✓1. �i JAL . � , who is personally known to
me or who has produced
identification and who did take an oath.
as
NOTARY PUBLIC:
Elizabeth Sandoval
NotaryPublic-StateofFlorida
Sign:8 I- Commiqsion 9GG 30615
Expires 3!27/2020
Print: �I -
Seal: 11 „q F�, r 9ondoa Yhtu Notary Public uncetwnmMI J Seal:
APPROVED BY �—:--> 1 r�cl� Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)