PL-04-191BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building Electrical
Owner's Name (Fee Simple Titleholder) M I &`ae L J - K l Phone # t/&
Owner's Address / o rto S rlv 2 C±
City ) 5 State F
Tenant/Lessee Name Phone #
Job Address (where the work is being done) 5 "` ___
City Miami Shores Village County Miami- IIde ' Zip
Is Building Historically Designated YES NO
Contractor's Company Name 5-2324-- Phone
Contractor's Address
City State Zip
Qualifier
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit a, 00 (.7 Square Footage Of Work:
Submittal Fee $.� 1 - Permit Fee $
Notary 5—r - b c) Training/Education Fee $
Scanning $ Radon $
Total Fee Now Due $
(Continued on opposite side)
,Li
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Te : �`s ° ��'ii :: 756.8972
JUL 0 g ?O"
Permit No. ?L y - l 611
Master Permit No.
Zip 3313
Type of Work: ['Addition ['Alteration New ❑ Repair/Replace ❑ Demolition
Describe Work: Seri A 1e,- ( Tre 6'1 -S StP�M - — hfi
1 0 G- CIC A.,, 4. L. el I.
Mechanical Roofing
CCF $ D CO /CC
Technology Fee $ c D
Zoning Bond $
Code Enforcement $ Structural Plan Review. $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address CCA bay - / QOATI et-el 2
City S clt�c State kJ r Zip 0 7 2O r -Yo o-J
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 CONDMONERS, 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 th 'is z el bf'a TI #'a it w h estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the ._i e f 8o c'e II t-�ia a - I con lru Eton lien ; aw brochure will be delivered to the person
whose properV is subject to attachment Also, a certifie copy" 44/ the r ea ott _ o commencement must be posted at the job site
for the first action which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the
inspection will t b • ap /r ov ' and a • inspection fee will be charged.
i _ f
Signature
' Contractor
The foregoin instrument ac ' ' 4 ged before me this The foregoing instrument was acknowledged before me this
day of 20 D L, b 50.VKIei C.\(t1"v , day of ,20 , by
who • • rso y known to me or who has produced =.1. who is personally known to me or who has produced
As identification and 4h%cl i7k ath. as identification and who did take an oath.
!..
NOTARY P' r : ?i�: • °•� : Commissi t D231984 NOTARY PUBLIC:
Sign: ir' Jul 3, 2007
Sign:
Print:
My Commission Expires:
Signature
* * * * * * * * * * * * * * * * * * * * * * * **
Chc 05/13/03
Owner or Agent
*** * * * * * * * * * * * * * * * * * * * * * * * * * * *,* **
APPLICATION APPROVED BY:
is Bonding Co., Inc.
Print:
My Commission Expires:
* * * * * * - * **
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At 1 Plans Examiner
per
2 ,,, Ar i.
Engineer
Zoning