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490 NE 101 St (5)Miami Shores Village Building Department 10050 NE 2 Ave, Miami Shores, Fl 33138 Tel: (305)795 -2204 - Fax; (305)756 -8972 PLEASE PRINT { DATE: ( / � -O L 7 - � TIME:1 NAME OF PERSON REQUESTING FILE: (VC) PHONE #: 75" S-3-- 7 OUR ADDRESS: t i q 0 A/ O f Sy s( / ADDRESS OF FILE REQUESTED: LOO E ' ( 5 f INFORMATION REQUESTED: d O r5 L co, s oProvcck I understand that all documents in this file are property of Miami Shores Village and that NO documents may be removed from this file. You may get 4 complementary copies (8x11) size, additional copies will be furnished at 0.15 cents per page, not including any blue prints. If blue prints are order please be aware that we are not responsible for the quality of the printed documents. Acknowledged b FILE RETURNED TO: INITIAL i1i 1�� Inspection Date: 07/27/2006 Inspector: Grande, Claudio Owner: BLOOM, MARK Job Address: 490 101 Street NE Project: <NONE> Contractor: Miami Shores Village, FL Comments Wednesday, July 26, 2006 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP -23273 cL Permit Number: BP2004 -1311 JUL 2 8 RECD Block: Permit Type: Imported Permit Inspection Type: PAINTING Work Classification: <NONE> Phone Number 786/253-7552 Parcel Number 1132060170430 Lot: Page 1 of 2 y . ms--, Passed Inspector Comments Failed Correction Needed Re- Inspection Fee ($75) No Additional Inspections can be scheduled re- inspection fee is paid. until Inspection Date: 07/27/2006 Inspector: Grande, Claudio Owner: BLOOM, MARK Job Address: 490 101 Street NE Project: <NONE> Contractor: Miami Shores Village, FL Comments Wednesday, July 26, 2006 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP -23273 cL Permit Number: BP2004 -1311 JUL 2 8 RECD Block: Permit Type: Imported Permit Inspection Type: PAINTING Work Classification: <NONE> Phone Number 786/253-7552 Parcel Number 1132060170430 Lot: Page 1 of 2 BUILDING PERMIT APPLICATION FBC 2001 Permit Type (circle): Owner's Name (Fee Simi)) T e Owner's Address / (�I City i i 5 &.e, e Tenant/Lessee Name City State $ Value of Work For this Permit Training/Education Fee $ Radon $ Total Fee Now Due $ I v (Continued on opposite side) Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 er) P , �� V� � e_loart. Phone # 1 O( 6f- State r i Electrical Plumbing Mechanical L (70 ma 101 Job Address (where the work is being done) City Miami Shores Village County Miami -Dade Is Building Historically Designated YES NO / goo o Zo Master Permit No. Zip 33 I Phone # Permit No. Zip Technology Fee $ Type of Work: ❑Addi 'on ❑Alteration ❑New Repair/Replace Describe Work: — (7,1,01— x i--0 Code Enforcement $ Structural Plan Review. $ �— 7A - 25 - 3 Contractor's Company Name Phone # Contractor's Address Zip Qualifier State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # Square Footage Of Work: ,I "" * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ OV ` ee Permit Fee $ 0., c CCF $ CO /CC Notary $ Scanning $ Bond $ oc ECEOVED 2004 Roofing ❑ Demolition 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. 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 COMMENCEME NT." 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 reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this 3 day of SEPT , 200y , by M who is personally known to me or who has produced ! ` As identification and who did take an oath. NOTARY P Print: IV 1 C;1EL— A. AL l Sign: My Commission Expires: Michael J. Alterio x " �E�s?tctlfflm' 13siolt# lak2+ 46M7 c***************** a***** * * * * * * * * * * * * *a * * * * * * * * * *** * * * ** Expires: Aug 13, 2007 Bonded Thru din ., Inc. ****************************** �k414k***** ' c * * * Bon * *1 Co * * * * * * * * * * * * * * * * * *..si„ ***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** a• . APPLICATION APPROVED BY: Chc 05/13/03 Signatur 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: OCT - 5 2004 Plans Examiner / / Engineer ��� 2 /0( �/ 0y Zoning ate — -755;Z /� V (3 �01A �j -,253 Owner's Name �r � Owner's Address L i 0 e- to ( f) Ui Shows • State Flower bins Shutters N1 A N/A i/ /A Doors and door jams Ao NA) 1446 /A Awnings Chimney Garage doors Railings Fences Decorative metal Signature Miami Shores Village Paint Color Approval and Agreement J/ A � to, W/4 All brick (simulated or regular) Stucco banding A Any other stucco features / Accessory Buildings / AY applicable laws regulating construction an APPLICATION APPROVED BY: 4 • z(1 1 Owner or Agent Zip L /y0 A l� j s� Job Address (where the work is being done) City Miami Shores Villa= County Miami-Dade Zip Is Building Historically Designated YES NO Contractor's Company Name (if applicable) Phone # ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** All elements on the site must be listed and indicate the color to be painted Walls ArIPOr n/��{ot,o . Fascia N� (to-tA ar d "i- c_C.d Drip Cap /drip Edge Au4-ukk 0 41116 Soffit c Sci-e, --J 'LAO al IV Roof / A I.A-otlotj Phone # 1 Body: Arbor Hollow ECC- 37 - 2 Trim: Eastern Wind ECC -24 -2 3 Accent: Autumn Hills ECC -24 -3 Other A i A ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all g. Date o7_o1?_o1/ Date io)(1)0g chc 6/18/03 Date Owner's Name City Flower bins Shutters Awnings Chimney Doors and door jams Garage doors Railings Fences Decorative metal Signature Miami Shores Village Paint Color Approval and Agreement q (A _ c& oorn Owner's Address LQ O E 1 0 ( 54-- Sk6\4 State 1 Job Address (where the work is being done) �q 15 101 S -. City Miami Shores Village County Miami -Dade Zip Is Building Historically Designated YES NO (r-' Contractor's Company Name (if applicable) Phone # ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** All elements on the site must be listed an indicate the color to bepainted 5 G Walls l''AT /. Fascia gcU-x\-L W Drip Cap /drip Edge 1°t-I.A.A. k-kl ,` S Soffit P n v,3111 C� OWNER'S AFFDAVIT: I certify that all the foregoing applicable laws regulating construction and zoning. Phone # Zip 33138 A tt / NI 16- �1 NIA All brick (simulated or regular) N ( 1n Stucco banding J 1 Any other stucco features N A Accessory Buildings (\.1 Other N f ************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** be done in compliance with all APPLICATION APPROVED BY: CSE Date 3 60/ fi( 0 Date J 3,©\ ©5 chc 6/1$/03 Building Permit Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Permit Number: BP2004 -1311 Printed: 10/6/2004 Applicant: MARK BLOOM Owner: BLOOM MARK JOB ADDRESS: 490 NE 101 ST Contractor Local Phone: Parcel # 1132060170430 Contractor's Address: Legal Description: 6 53 42 Page 1 of 1 PB 15 -14 AMD PL OF MIAMI SHORES SEC 4 LOT 1 BLK 90 Fees: Description Amount FEE2004 -9840 Building Fee $60.00 FEE2004 -9841 CCF $0.60 FEE2004 -9842 Training and Education Fee $0.20 FEE2004 -9843 Technology Fee $1.50 Total Fees: $62.30 Total Fees: $62.30 Total Receipts: $50.00 Permit Status: APPROVED Permit Expiration: 3/30/2005 Construction Value: $1,000.00 Work: EXTERIOR PAINT Signed: (INSPECTOR) ziolz In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work done by either myself, my agent, servants or employes. Signed: (Contractor or Builder) BY: t / 47i Fl c Miami Shores ge 6( , Pa int Color Approval and A reethent Date Lf• 5 Owner's Name AAA ; M12$ 31 Owner's Address t/9 /f E /d/ sY City / /A-1-4 5dot3E State ri Job Address (where the work is being done) Le Rd d. c • 101 s� City Miami Shores Village County Miami -Dade Zip 3313g Is Building Historically Designated YES NO ✓ Contractor's Company Name (if applicable) Phone # pp All elements on the site must be listed and indicate the color to be painted Walls /l / /i7• Fascia /4- Drip Cap/drip Edge CD/'(L�r\ t . COPPER 6'006 Soffit 071_, — 7 Roof NO, Flower bins / l/4' N1 /A Doors and door j t o s Court - r(�( WE-vJbc9 Garage doors �1 Railings v5 (,oM 1 N (o O � ■rr 4< Fences 1.11tt Decorative metal NJ A All brick (simulated or regular) ilik Shutters Awnings Chimney Zip 33137 Stucco banding Ni Any other stucco features v41 tDIEN 1 Aervgg — Coo" ""1 1261)400k), Accessory Buildings Other ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Signature A 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. APPLICATION APPROVED BY: o Owner or Agent Phone # `f &�o i&i Date Date /5/0 W Chc6 /1803 CirY 1 Miami Shores Village 10050 NE 2nd Avenue Phone: 305- 795 -2204 Permit Number: BP2002 -1303 Printed: 7/26/2002 Applicant: MICHELLE MULLANE Owner: MULLANE MICHELLE JOB ADDRESS: 490 NE 101 ST Contractor Local Phone: Parcel # 1132060170430 Fees: Description Amount FEE2002 -4118 Building Permit Application Fee $60.00 FEE2002 -4120 CCF $0.60 FEE2002 -4121 Notary Fee $5.00 $65.60 Total Fees: Total Fees: $65.60 Total Receipts: $0.00 Permit Status: Approved Permit Expiration: 1/21/2003 Work: PAINTING If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection fee is $50.00, which must be paid in advance before calling for another inspection. Bank:of4i ;e,lca,4duq (ag4 THOMAS M. MULLANE OR MICHELL B. MULLANE �, 63 27/631 FL MIAMI, N.E. 101 T 8 7 ( - 1 1 °2- MIAMI, FL 1 8 pale � ( ' 1 $ ,,,L5- Pa v •tte (>16 4,--- /- 1.02-t, a ( Inllu'n'lern/ / /. k) r- 4 :,.. t s:-_-(.: . oc „.__ BankofAm ic ACH R/T 063100277 Memo ':06 3 100 2 7 71:' 00350488756711' 2754 Contractor's Address: Building Permit Legal Description: 6 53 42 Construction Value: 2754 BY: BY: Page 1 of 1 PB 15 -14 AMD PL OF MIAMI SHORES SEC 4 LOT 1 BLK 90 e equipment or device described in the application herefor in strict compliance with all vith any plans, drawings, statements dr specifications that may have been submitted to not done in compliance with such ordinances or if the plans are changed without tor or builder named above assumes the responsibility for a thorough knowledge of the gs or in the statements or specifications and that he assumes responsibility for work done compliance with all ordinances and regulations pertaining thereto and in strict conformity s Village. In accepting this permit I assume responisibility for all work done by either MIAMI SHORES VILLAGE Paint Color-Approval and Agreement DATE: 7 , 3 ( 0 2, OWNER'S NAME: i l,bmtY v VYntck,1 t4 �1u,( PHONE: 757 co ADDRESS: 4q N tc01 F -S ************************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ences Decorative Metal (� / All brick (simulated Stucco Banding Any other stucco features Accessory Buildings Other Building Offi ADDRESS OF SITE: /!v- CONTRACTOR & LICEN E (if applicable) N COMPANY NAME: 0 ,84,- PHONE :'I` / * * * * * * * * * * * * * * * * * * * * ** ******************************4********** All Elements on the site must be listed and indicate the color to be painted. r— Walls c 5c , Fascia /� / ) Drip Cap/Drip Edge , 3 Soffit . N I )1- Roof f\I Flower Bins 4 Shutters N Awnings N) ,. i Chimney N , �t o Doors and door jams �. --- �`� ' c Gara Doors UI b t u Railings to F En OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all appli,e'able laws regulating construction and zoning. I authorize the above -named contractor, if applicable, to do ork s' • ted. F ' rthermore , the paint colors w;,l1" be as per the attached sa • 0 0 t 7 2- ignatur wner • to Signature of Contractor Date *********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED: • - WHEN PAINTING IS FINISHED, 7P or y rn.v( Valor �,or�e�i CALL FOR FINAL INSPECTION b y C�hi 7/ 0 Date 4/23/01 The Sunshine State LICENSE NUMBER M450-542-63-6054 MICHELLE 8 MULLANE 490 NE 101ST ST MIAMI SHORES, FL 33138-2449 ERWIN DATE SEX H3T. REST. ENDORSE. 03-2543 F 5-11 ISSUED EXPIRES DUPLICATE 03-18-88 03-25-02 00.00.00 4 SO:198031toom Operation of a moor vehicle constitutes consent to any sobriety test required by law. PROPERTY OWNER New Construction N om, ort.q s + hA.c J l._ YYN LA-(10. Ad4 ss 9 o isr N_ ay i iSVIdwe Home Telephone 7 -sg, 3'7 (. _ �° Business Telephone A � Repair Fax ^ ,' Alteration Interior TYPE OF MANAGEMENT (✓ ) New Construction Enclosure Alteration Exterior Repair Alteration Interior Demolish Relocation of Structure Shell Only Foundation Only Add'I Attachment Other Add'l Detachment Other f r ob Address: l "1© N C-1 0 1 tf Address Step 1. Folio Number Description o orf W k IC�?A_Gk Lot Block Subdivision PB PG Current Use of Property Proposed Use of Property Tenant Information PERMIT TYPE (✓ ) Building Electrical Mechanical Plumbing LPGX Roofing Fence Other ARCHITECT Name License No. Address Telephone Fax Apt. Zo PERMIT CHANGE (✓ ) Chg. Contractor Renewal Revision Extension Supplement Reinspection Master Permit No. Subsidiary Permit No. ing PERMIT APPLICATION 0 . INSTRUCTIONS - The following steps must he 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 submit- ted 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. A PPLICATION m 1 Q - ( We City State Zip Y l Linear Feet Square Feet Units Floors ,alue of Work y 0 ° 0 6 Bldg Value Tax Assessed/Appraised Value Flood Zone Base Floor Elev. ENGINEER Name License No. Address Telephone Fax CONTRACTOR Name License No. Address Telephone Fax Qualifier Name Page 2 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 ELECTRICAL, 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. STAT OF FLORIDA, CO Signature of Owner 6 Q \l, € M of Flori Print Name _ _ Print Name SEAL: to and subscribed before me this ure of No Publi Personally known AMI -DARE p � P ttY PU/ ANC A l M vi co., . 'd:S_'- NUMBER STATE OF FLORIDA, COUNTY OF MIAMI -DADE Signature of Contractor / Qualifier Sworn to and subscribed before me this day of Signature of Notary Public - State of Florida SEAL: PERMIT APPLICATION -9, . c i.s. MY COMMIS:JON EXPIRES NOV. 15,2002 OR, Produced Identification` Personally known OR, Produced Identification � I 11 / Type of Identification Produced: �`2_DL TY\ tS 0 5 7 �' 63 - 6 blype of Identification Produced: ELECTRICAL TYPE Minimum Fee QTY TYPE: Dryer QTY. TYI , l ,. Outlet, Appliance (yi y 1 . ) 1 Service Repair Q . Q . Y . A/C Central 1 -3 Ton Fan Outlet, Wall Service, Temporary A/C Central 4 -7 Ton Fire Pump Outlet, Switch Signs A/C Central 8 -15 Ton Fixture - Fluorescent Oven Space Heater (kw) A/C Central 16-20 Ton Fixture Light Parking Lot Lights Spas/Hot Tubs A/C Central 20+ Ton Flood Lights Plugmold/Strip Subfeeds, No. of Amps A/C Window FPL - Load Central Posts Swim Pool, Commercial Air Conditioners Garbage Disposal Range/Range Top Swim Pool, Residential Chiller Generators, etc. Receptacles Switchboards Clear Violations Heat Recovery Refrigerator, Comm. (p/PH) Temp Serv., Construction Compactor Low -volt, Burglar Refrigerator, Domestic Temp for Test - 30 days Deep Freezer Low -volt, Fire Renew - Temp Service Water Closet Demolition Low -volt, Intercom/Teleph. Repair Circuits Water Heater Dishwasher Low -volt, Television Service, Number of Amps Water Heater New MECHANICAL TypE Minimum Fee QTY. TyPE Condensate Drain QTY. TY Generator (yr . HYPE': Refrigeration, Tons QTY. A/C Central, Tons Cooling Tower Heating Strips, each Vent Hood, Cost A/C Wa1WVin. 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 Supply, AC Well Bath Fan - Vented, # Fireplaces, Number of Pressure Vessel Temporary Toilet PLUMBING TYPE A/C Condensate QTY. TYPE Drains, Roof QTY. TYPE Miscellaneous Fixture QTy. 'fYPF Soakage Pit Q'fy. 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 PERMIT APPLICATION INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below. RECEIVED AND REVIEWED BY: DATE: SECTION BY DATE Zonin: /7. ; Electrical Mechanical Plumbing Fire Public Works Structural Building Official v/ Page 4 OFFICE USE ONLY CHECKLIST O OWNER - BUILDER FORM (Attach) LI FIRE DEPARTMENT APPROVAL (Commercial / multi - family) ❑ CONCURRENCY (New Construction) ❑ OTHER (Specify & Attach) $3.00 per page (Scanning Fee) Miami Shores Village Bond Metropolitan Dade County (C.C.F.) $ Inspector State Educational Fund $ State DCA (Radon) $ Code Enforcement Fine Zoning Review Notary ❑ PROOF OF OWNERSHIP (Attach) O HRS / DERM APPROVAL (Septic / Sewer) ❑ IMPACT FEE (New Construction) ❑ OTHER (Specify & Attach) PERMIT FEES o $ $ _S c) ( sq.ft. = x/1000 x ¢.60) (¢.005 /sq.ft.) (¢.01 /sq.ft.) PERMIT APPLICATION Cl CONDO ASSOCIATION APPROVAL (Attach) ❑ BPR APPROVAL (Restaurants) ❑ CONTRACTOR REGISTRATION (On File) TOTAL $ ISSUING OFFICIAL REVIEWED AND PREPARED BY: DATE: 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 PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date Ilk 3 11`3s Job Address t 't 50 \El 0 I ST n, - S Tax Folio Legal Description Historically Designated: Yes No Owner/Les-see / Tenant m H e t l e 1 ! \CD' no f "w -Lk3t- r \ Q _ _ Master Permit # 3 g � Owner's A d d r e s s 4c' NE- ST Phone 7 9 3 3 Contracting Co. O t..c.) rN p Address Qualifier SS# Phone State # Municipr' Competency # Ins. Co. Architect/Engineer Address Bonding Company Mortgagor Address Address Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION � C ,� cV=001, Square Ft. Estimated Cost (value 7 pJ) ( F A 2Cf e'- ( ak WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO 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.) Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I 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 ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK. 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. Furthermore, I authorize the abov ed contractor to do the work stated. FEES: PERMIT 40 RADON Ce / 3 / 4 :c -- Signature of owner and/or Condo President Date Signature of Contracto •r Owner- Builder Date Notary as to Owner and/or Condo President Date Notary as to Contractor or Owner-Builder Date My Commission Expires: M ' s • u,� vn yid gl;�rii NOTARY s�At. 0 e 7i SANDRA M MONT! . 2 w . * COMMISSION NUMBER A 4 n�; < ® CC401261 7 n MY COMMISSION .EXP. OF r=■. AUQ, 1 'Ono C.C.F. NOTARY - a v TOTAL DUE q /2// /fl" APPROVED: ,{ Zoning Building q'i.41Y6 1 Electrical Mechanical Plumbing Engineering