ELC-11-388Miami Shores Village G, t
Building Department io 0 4 ""
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 �`- 6
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305). 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit No.
EIGII -3dS
Master Permit No.
Permit Type: ELECTRICAL
Owner's Name (Fee Simple Titleholder) 6 C (` d Phone #
Owner's Address 1A`33 Cr.._ 0- —�c■,->-�
City ----A S'5 State c----Cc cc�
Tenant/Lessee Name
Email
Zip 3-3I, ?j�
Job Address (where the work is being done) 0 i L__Ct 0c3kke\\ 6 c!
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL #
Is Building Historically Designated YES NO Flood Zone
Phone #
MC) is
_ c c . Contractor's Company Name 'o c1 Phone # '3S — -7 sa- L)
Contractor's Address 6(c,, ci (.J CC Z� ,s _c____4—
City (N.6. ck.,,ot, State Cc--ci. Ac. Zip 3 \S 6
Qualifier Name S°U�- s-.csc- \ Phone # 3(..---.--- '7' — DZ t1,
State Certificate or Registration No. -EL `\ ck c 1 Certificate of Competency No.
Contact Phone 30s- -) S - cc Lac) E -mail is ccaL9-_C?
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ Square / Linear Footage Of Work:
Type of Work: EAddition ❑Alteration ❑New
❑ Repair/Replace ❑ DemoIirion
Describe Work: \ 6 '\ C
******* * *** * * * * * ** ** ** * ** *** * * * * ** * * ** Fees * ** * * * ** * ** r* * * * * ** * * ** * **** ** * * ** * * ** ** * * **
Permit Fee $ CCF $ CO /CC $
Submittal Fee $
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Bond $
Double Fee $ VioIation date:
Structural Review. $ Total Fee Now Due $
See Reverse side --+
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State
Nip
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 re- inspection fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this
day of , 20 , by
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
l/
APPROVED BY Ont/f 9 y\--1 /v — Plans Examiner Zoning
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 _, by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
Clerk checked