PL-14-170 (2)a�IdP Miami Shores Village
\ p� Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 7952204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
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BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
Permit No.
CANCELLED
Master Permit No.PL N — k 10
JOB ADDRESS: & 111 N W 103 st
City: Miami Shores County Miami DadeS®
Folio/Parcel#: I)- 213 (a -Q 13 - I S l o
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): IWA e*G a+ V j v-iCen+ L eVrr Phone#: QS 3 2 - �� 9
Address: N W L o'b St
City: f'ANV�W ASS State: M Zip: 3 3 15 O
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: A4 A a ro "' Q o a✓ Phone#:
Address: Gall Su) -65 cr
City: $0"Y-04 e% aw/ State: FL Zip: 3 3 a Z 3
Qualifier Name: 5-ah'n 'C. Ji Phone#- 3
State Certification or Registration #: JJ Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Atchitect/Engineer. Phone#:
Value of Work for this Permit: $ 3 00 O a° ' Square/Linear Footage of Work:
►5o
Type of Work: ❑Address ❑Alteration ❑New )Repair/Replace ❑Demolition
Description of Work:
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Submittal Fee $ Permit Fee $�` /� y CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Zip
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC.....
OWNER'S AFFiDAV1T: 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of comm ement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. I t e absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signaturex 46", aZ Qitlhed
Owner or Agent
The foregoing instrument was acknowledged before me this 2-5
day of et r1 20 ((1, by %� l c �' L.-yws
who is personally known to me or who has produced RPr OY 1V
r$
As identification and who did
NOTARY PUBLIC:
sign:
Print:
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My Commission Expires:
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APPROVED BY
Contractor
The foregoing instrument was acknowledged before me this
day of r 20( bvt 01n Ty __a
who is personally known to me or who has produced)
OV-VV LIC&, as identification and who did take
Structural Review
NOTARY PUBLIC:
Sign
Print: -T-A2,ef L
My Commission Expires:
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Zoning
Clerk
(Reviso /12/2012)(Revised 07/10/07)(Revised 06/10/2009XRevised 3/15/09)