EL-10-09-1768BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type: Electrical
Owner's Name (Fee Simple Titleholder)
Owner's Address (25 N v( 9 2vi 17
City M i Q VY►1 SHUR.ES State t LO
Tenant/Lessee Name
E -MAIL:
Job Address (where the work is being done)
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated YES NO X
Contractor's Company Name P1 N Nae LE Sl.0UC 11 l.L G
Phone # 11-1 123
Contractor's Address 12- Q S a lV p t-A l L L 4
cit Omm state UTaN Zip V-105e
Qualifier Name ,,)0∎ ti< Phone# S Z 53
State Certificate or Registration No. EG (3 q Certificate of Competency No.
E -MAIL: a•eS\AY) C li seCCp_ttj•
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ q q > 0
Type of Work: ❑Addition ❑Alteration
Describe Work: (NST61 TIoN aI LOW
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Submittal Fee $�/ O • VV ^1 Permit Fee $ 6 r CP 6 CCF $ O•(00 CO /CC
0 , .0 Technology Fee $ 2.S(
Notary $
Scanning 6.00
Bond $
Structural Review. $
rr ,
Miami Shores Village
Building Department
>0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (3! __ . 95.2204 Fax: (305) 756.8972
�-
331751W
e C j DA G A -1zVPr L t rO Phone #
Square / Linear Footage Of Work:
ew
CL_ 10-0 fv
Permit No.
ster Permit No.
�o5 76 2
❑ Repair/Replace ❑ Demolition
F? RG ' Pt S`fsWM
Training/Education Fee $
Radon $ DPBR $
Code Enforcement $ Double Fee $
Total Fee Now Due $ 5(Q" t5J
Zoning $
See Reverse side ->
PillnUGIB e 5o1 k131 -0 1O32 wiAANI P4"v1rf
P (S YeA or a `L 4-v P
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. 1 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
COMMENCEMENT."
Signature
The for
day of
NOTARY PU
IC:
Si
Print:
My Commission Expires:
APPLICATION APPROVED B
(Revised 02108/06)
ally known to me or who has produc
w o is pers
As identification and w
***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
rT
Notice to Applicant: As a condition to the issuance of a buildi�
promise in good faith that a copy of the notice of commencem
whose property is subject to attachment. Also, a certified copy o
for the first inspection which oc even (7). days after the buil
inspection will not - approve inspe ion fee will be charged.
and a r
20 01 by —LICA& C adViAl
L
Nmit with an estimated value exceeding $2500, the applicant must
onstruction lien law brochure will be delivered to the person
.ded notice of commencement must be posted at the job site
rmit is issue -.� the absence of such posted notice, the
Signatu
�" Owner gent
i strument was acknowledged before me this The foregoing
day of
who is personal]
oath.
'9
r o R #
'NO q‘‘. r' �O
0 If . o
NOTARY PUBLIC:
't
di tt
My Commission Expires:
***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
r
Contractor
was acknowledged before me this
by — Sex CIL 4 . oi.l\ft
or who has produced
as identification and who did take an oath.
Plans Examiner
Engineer
Zoning