EL-12-16-3421, 141 NW 96th StL�
Miami Shores Village
`gt�ORES
� e
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
Phone: (305)795-2204
F�ORtDP
(Permit
Permit No. EL-12-16-3421
Permit Type: Electrical - Residential
Work Classification: Service Change
Permit Status: APPROVED
Issue Date: 12/22/2016 I Expiration: 0/2/2017
Project Address
Parcel Number
141 NW 96 Street
1131010250110
Miami Shores, FL 33150-
Block: Lot:
Owner Information
Address Phone
PETER GOLDSMITH
141 NW 96 Street
MIAMI SHORES FL 33150-
141 NW 96 Street
MIAMI SHORES FL 33150-
Contractor(s) Phone Cell Phone
INDUSTRIAL ELECTRICAL SYSTEM C 305/228-1384
Type of Work: CHANGE ELECTRICAL SERVICES
Additional Info: CHANGE ELECTRICAL SERVICES
Classification: Residential
Scanning: 3
Fees Due
Amount
CCF
$0.60
DBPR Fee
$2.25
DCA Fee
$2.25
Education Surcharge
$0.20
Permit Fee - Additions/Alterations
$150 00
Scanning Fee
$100
Technology Fee
$0.80
Total:
$159.10
Applicant
PETER GOLDSMITH
Cell
Valuation: $ 1,000.00
Total Sq Feet: 0
Pay Date Pay Type Amt Paid Amt Due
Invoice #
EL-12-16-62415
12/20/2016
Credit Card S 50.00 $ 109.10
12/22/2016
Credit Card S 109.10 $ 0.00
Available Inspections:
Inspection Type:
Review Electrical
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 that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zo6ina. IiMore, I authorize the above -named contractor to do the work stated.
December 22, 2016
Authorized Sig ature: Owner / Applicant / Contractor / Agent
Building Department Copy
December 22, 2016
Miami Shores Village RECEIVED
Building Department DEC'
DEC' 2 0 2096
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 201(A
BUILDING Master Permit No. Z�
PERMIT APPLICATION Sub Permit No.
❑BUILDING Q ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /T ! V (('
City: Miami Shores County: Miami Dade Zip: 3-t1 ST
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type:
OWNER: Na/me (Fee Simple Titleholder): �� �✓
Address:
a///
City: , (C�!lies State:
Tenant/Lessee Name:
Email:
CONTRACT/OrR: Company Name: p-4—'/C
Address: I
City: 0,
Qualifier Name: �es�ati
If
Flood Zone: BFE: FFE:
h
�( u �(49e S Phone#:50S-22-8— (3?l
Zip: ?3 f g3
ne#:
State Certification or Registration #: EC /30 0 2 R8 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
Phone#:
State: Zip:
Value of Work for this Permit: $ /0_41'9' rb Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration / ❑ New ❑ Repair/Replace ❑ Demolition
Description of.Wock:�z.� 4�' L' l e �'t7�-LGc S2�✓1 GP_,�
Specify color of color thru tile:
Submittal Fee $rJ0( Permit Fee $ / 5 !J� CCF $ V CO/CC $
Scanning Fee $ _ L ) Radon Fee $ 2 • o21 DBPR $ oZ4 Notary $
Technology Fee $ U • (En Training/Education Fee $ V Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ d
(Revised02/24/2014)
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 a,fter the building permit is issued. In the absence of such posted notice, the
inspection will not be approved rei ection fee i J �q1 be charged.
Signature / Signature,
NER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
7i% day of 20 by� day of 20 _J by
/ �%�/t ,who is personally known to /V� IG OW65i who is personally know n
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTAR;PUAC: NOTARY PAC:6
Sign: Sign:Print: OE SALGUEIRO Print: ° IicState of Florida
Notary Public state ot mon(Ta = Comm ss on
Seal: • ; ; • c Commission # FF 245464 g, Seal: = rs +off= My Comm. Expires Jun 30, 2019 r
�N9 cl,,a:° My Comm. Expires Jun 30, 2019 �''%. ; F`•, Bonded through Naticnal Notary Assn ''
Bonded through National Notary Assi
******************** ************************************************************************************
APPROVED BY ZC��L Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)