EL-02-59PROPERTY OWNER
Name
3, KJ vef , `
Address
1 kilo a M E= gr1 Ve
Home Telephone
Business Telephone
Fax
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'l Attachment
Other
Add'l Detachment
Other
Step 1.
Job Address: (0 0 1 1A) / 1' 5 6.5 -e
Address
Folio Number
Lot Block
Subdivision
Current Use of Property
Proposed Use of Property
Tenant Information
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
PB PG
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
PERMIT APPLICATION
Master Permit No. 1t' c) —DI — 1 165
Subsidiary Permit No.
Oil -
INSTRUCTIONS - The following steps trust be taken to obtain a permit from the Miami Shores Village:
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
y f j$I,®ne -. `3313E
Apt. City State Zip
escription of Work .1 l® C J cAzi
ti po f —7,1° pu -"? L4-
Zoning Linear Feet
Units Floors
Square Feet
A gue of Wo
Tax Assessed/Appraised Value
Flood Zone Base Floor Elev.
Bldg Value
ENGINEER
Name
License No.
Address
Telephone
Fax
Page 2
PERMIT APPLICATION
IMPORTANT NOTICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, certify that all
work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
are required for FJ.RCTRICAL, PLUMBING, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1" Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STATE OF FLO COUNTY OF MIAMI -DADE
S tore of Owner
Print Name
Sworn to and subscribed before me this day of
Signature of Notary Public - State of Florida
SEAL:
• & '
•
Print Name
,, . re . nd subscribed before me this
/ /I !%r 111
Si .. e of Ni; • j Public
Ai
S : to of Florida
'91
day of
STATE Q ID A, CO /J'' Y OF MIAMI -DADE
r �. n_ 1 f' / .L
�
" In. tore of Contractor / Qualifier
SEAL:
,‘p•RY PU,s,I b Clfi �4 6sCQER
, c
iJ * i29!� q.�rd NUMSER
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o• MY COMMISSION EAMES
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Personally known OR, Produced Identification Personally known ))
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ELECTRICAL
TYPE
Minimum Fee
QTY.
TYPE
Dryer
QTY. TYPE
Outlet, Appliance
QTY.
TYPE
Service Repair
QTY.
A/C Central 1 -3 Ton
Cooling Tower
Fan
Outlet, Wall
Service, Temporary
A/C Central 4-7 Ton
- Paint Booth
Fire Pump
Outlet, Switch
Air Handler, Tons
Signs
Ductwork, Cost of
A/C Central 8-15 Ton
Periodic Inspections
Fixture - Fluorescent
Oven
Space Heater (kw)
- Process/Pressure Piping
A/C Central 16-20 Ton
Fixture Light
s Parking Lot Lights
9 i :
Spas/Hot Tubs
Gas - Appliance
A/C Central 20+ Ton
Pump, Domestic
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Temporary Toilet
Swim Pool, Commercial
Catch Basin
Air Conditioners
Gas - Propane
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Pump, Replace - Pool
Switchboards
Urinal
Clear Violations
Dental Chair
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Ice Maker
Temp for Test - 30 days
Pump, Sump
Deep Freezer
Utility - Water
Low -volt, Fire
Renew - Temp Service
p 0 1 eA '51'
ID
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Disposal
Interceptor
Dishwasher
Roof Inlet
Low -volt, Television
Service, Number of Amps
itt
Iifidifhnfha
MCCI- IANICAL
TYPE
Minimum Fee
QTY.
TYPE
Condensate Drain
QTI'. TYPE
Generator
QTY. TYPE
Refrigeration, Tons
QTY.
A/C Central, Tons
QTY.
Cooling Tower
- Heating Strips, each
Vent Hood, Cost
A/C Wall/Wm. Tons
Dryer Vents, Number of
- Paint Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
- Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
- Process/Pressure Piping
Pump and Abandon
Bath Fan - Vented, #
Fireplaces, Number of
- Pressure Vessel
Gas - Appliance
PLUMBING
TYPE
A/C Condensate
QTY.
TYPE
Drains, Roof
QTY.
TY PE
Miscellaneous Fixture
QTY.
TYPE
Soakage Pit
QTY.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
PERMIT APPLICATION
RECEIVED AND REVIEWED BY: DATE:
Page 4
OFFICE USE ONLY
CI- IECKLIST
❑ OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi- family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
PERMIT FEES
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.) (sq.ft. = x/1000
x ¢.60)
Inspector State Educational Fund $
State DCA (Radon)
Code Enforcement Fine
Zoning Review
REVIEWED AND PREPARED BY:
LI PROOF OF OWNERSHIP
(Attach)
❑ HRS / DERM APPROVAL
(Septic / Sewer)
❑ IMPACT PEE
(New Construction)
LI OTHER
(Specify & Attach)
$ y.� pcao d
$
$
$
SECTION
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
BY
DATE
(¢.005 /sq.f.)
(¢.01 /sq.ft.)
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
�
TOTAL $
ISSUING OFFICIAL
DATE: 7...3 peg
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com