PL-15-2203Miami Shores Village
Building Department LBYop"4
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
fx_
2015
��4
FBC 20 H
Master Permit No. t
Sub Permit No. PL �
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
ME PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 10420 NW 2 AVE
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:11-2136-016-1050 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Jean & Marie Wilfred Phone#:
Address:10420 NW 2 Ave
City: Miami Shores State: Zip: 33150
Tenant/Lessee Name: NA Phone#:
Email:
CONTRACTOR: Company Name: MG PLUMBING & SPRINKLER Phone#: 9546135613
Address: 1265 NW 203 ST
City: Miami State: FL Zip: 33169
Qualifier Name: James W Nycum Phone#: 9542490709
State Certification or Registration #: CFC 056920 Certificate of Competency #:
DESIGNER: Architect/Engineer: NA Phone#:
Address:
Value of Work for this Permit: $ 180.00
Type of Work: ❑ Addition ❑ Alteration
Description of Work: kitchen sink
Specify color of color thru tile:
City: State:
Square/Linear Footage of Work:
❑ New ❑■ Repair/Replace
Zip:
❑ Demolition
f� �
Submittal Fee $y v Permit Fee $ �1��� CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Priding Company's Name (if applicable) NA
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
NA
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.
Signatur Jarinfl--
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of t 201f5 by
i who is personally nown to
me or who h produced as
identification and who did take an oath.
C — NOTARY_PU BL
,►� Notary Public Stab Of FIOMN
.4 H W Ellis Jr//%v4-1/&7-,
� I My Commission EE 1
Print:
Seal
Signatu Llpk�am '
CONTRACTOR
The fa&e=ing instrum ntpX ubas acknowledged befoorp th'
day�V�-r 28y
James W Nycum who is personally known to
me or who has produced - as
identification and who did take an oath.
NOTARY UBLIC: ro��rnueGn Nara ha MaS�smanFlorida
• My Commission EE 842290
�4�OF F�O� ExP, e 10112�2�16
Sign:
*ors*s*ss**s*s*r*******ss ss**�**ss+�s*ssss('ess:*s*as*s*s*sssssss::ssss�s*sssss*****�****::rssr�ess*sssrs***ss�s
APPROVED BY �i' 2�— I , Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)