PL-7-1354BUILDING
PERMIT APPLICATION
FBC 2004
Owner's Address
City ,A/,v\ 1
Contractor's Company Name A Plrf j -
Contractor's Address 1 153 1 6s f1 - s
City j4 01011 oren
Qualifier Name \j ] I a rt red 3A
State Certificate or Registration No. S PO ®d 5 1
E -MAIL:
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $ 2.0
Type of Work: ❑Addition ['Alteration
Describe Work: Nl^y 7 12. Po V
Submittal Fee $
Notary $
Scanning $
Bond $
*wwww**
?' C
Radon $
Structural Review. $
Code Enforcement $
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit Type: Plumbing
Owner's Name (Fee Simple Titleholder) agF/Y1tS V%J #+1 Phone # `it, -a L s c55
Ri CIE 92)/C1
State PL
Tenant/Lessee Name
E -MAIL:
Job Address (where the work is being done) B f'\!
City Miami Shores Village County
FOLIO /PARCEL# ii_ 371Ok - 0 .S 1— OO'2,Q
Is Building Historically Designated YES NO
Miami -Dade
State Zip 3 fl V
DPBR $
Certifica
w *xxmxxxx oYxxxxxxrxx*****F *****xxxxxxxx
Permit Fee $ d f4;� (15,6n CCF $1 :60
• Training /Education Fee $ (0 ;+
Permit No.
L .
aster Permit NoN,
Zip
Phone #
Square / Linear Footage Of Work: X
Zip
Phone # 3 s7 Ss i
',hone# 7 *, )
tency No. 5 ' 3
_.
Phone #
New ❑ Repair /Replace ❑ Demolition
ACS UNA C.. . c- Sy
Double Fee $
**
CO /CC
Technology Fee $ • 13
Zoning $
Total Fee Now Due $ ( -
See Reverse side -->
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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: 1 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'
COMMENCEM ENT."
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 af and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also a cert'fie4:, o of the recorded notice of commencement roust be posted at the job site
for the first inspection which oc� days aft� l ng permit is issued. In the absence of such posted notice, the
inspection will not be a p,oVed and cue
a reinspection fee will
•
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this — The foregoing instrument was acknowledged before me thi
day oNcit -/ .. , 20 U'1, b L c day of ■ L✓r"t , 20 Q`) , byr)t t.,tit ,x c.
who is personally known to me or who has produced who is personally known to me or who has produced
Signature
As identification and who did take an oath.
NOtainr LICSDVE OF,
Y PUBLIC" , , � a FidllQall- Atte
ton #D0+10112
miendellondIng Minis: C.
Sign:
riot:.
My Commission Expires:
xx vs. xxxxxxxxx
(Revised 02/08/06)
APPLICATION APPROVED BY:
Sign
xxx xxxxxxxxxxxxxx xxxxxxx m
�r►
as ii 'd-S"I"ATEdd %Meath.
NOTARY PUB I . k ,,, Donna Fiduccia -Arc+
Sign:
My Commission Expires:
csion #DD44i41
b res: JULY 31 2009
Om A Bonding �:o, Inc
******xxxxxxxxxxxxxxx xxx****
Plans Examiner
Engineer
Zoning