PL-05-19-1239Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
102 NE 109TH ST, Miami Shores, FL 33161
Contacts
Permit NO.: PL-05-19-1239
Permit Type: Plumbing - Residential
Work Classification: Alteration
Permit Status: Approved
Issue Date:06/06/2019 Expiration: 11/26/2019
Parcel Number
1121360090160
ELAN AND ANNE-CAMILLE HERSH Owner WESTLAND PLUMBING CORP
102 NE 109 ST, MIAMI SHORES, FL 331617042 CARLOS COBOS
675 W 63 DR ****
Business: 3058636223
Other: 7862360198
Description: NEW 4" DRAIN LINE FROM THE HOUSE TO NEW Valuation: $ 1,400.00
SEPTIC TANK
TotalSq Feet: 0.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$1.20
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.40
Permit Fee
$50.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$111.30
Inspection Requests:
305-762-4949
Payments Date Paid Amt Paid
Total Fees $111.10
Check# 19509 06/06/2019 $111.10
Amount Due: $0.00
Contractor
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 certify thaj_all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
reoulatina construation and zanina. fuilhermore. I authorize the above named contractor to do the work stated.
/ Applicant / Contractor / Agent
Date
June 06, 2019 Page 2 of 2
Miami Shores Village -
Building Department MAY
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 20V-1
BUILDING Master Permit No.,
1z 0— 19—SS �'
PERMIT APPLICATION Sub Permit No. PL- OS —I I— IZ J9
❑BUILDING ❑ ELECTRIC Ej ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
/�. CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1 'A(o - 0041 O 1 (00 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): E la n F is t sk Phone#:
Address: L O Z N E L O Q S i-
City: H r. ex" t SLoyof-e— State: -- Le r L CeA- zip: 33 It.
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address: IV
City: AlaA
Qualifier Name:
IT
State Certification or Registrationit: G1rL O W1l 1'7 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address: City: State: Zip: L
Value of Work for this Permit: $ 1 e}�[;� oo Square/Linear Footage of Work: &0 4.1rl eff ( 7'0CL
Type of Work: ❑ Addition ❑ Alteration ❑ New Z Repair/Replace ❑ Demolition
Specify color of color thru
Submittal Fee
Scanning Fee $
Technology Fee
Structural Reviews $
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $ 7x(
TOTAL FEE NOW DUE $
(Revised02/24/2024)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lenders 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. 1 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 INTENC
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 1` ,
OWNER or AGENT
-he foregoing instrument was knowledged before me this
2 0ayo1f 20 I'n1 by
klan ,, who is personally known to
me or who has produced h • L as
Signatu e
CONTRACTOR
The foregoing instrument was acknowledged before me this
Z 1
day of Ct i . 20 (q . by
C` S who is Personally known to
me or who has produced
as
identification and who did take an oath.
identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
Sign:
Sign:
Print: C i
Print:t
Seal: ..;a:'d ..,:,,
DARLING CENTENO
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Seal: .••""`� ,,
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Notary Public-StateofFlorida
Commission 4 FF 246599
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APPROVED BY 6 ���9 Plans Examiner Zonin€
Structural Review
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(Revised02/24/2014)