453 NE 102 St (6)MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date g 4-122 Time
.t Type Insp'n /
Permit No. 13p 2 6 x"! 1 3
Name ■ I >o r /P6/41
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a
Address
Company
Phone #
For Inspector: 4- 2 7 . e 2 Name & D
Approv-•
Correction
Re- Insp'n Fee
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Requ
Date Time
Type Insp' n M ht/r\
Permit No.
Name
— Address
Company
Phone # q j j�
, L; S
For Inspector:41 /o�
Approved
Correction
(3 7
Re- Insp'n Fee ❑
Da
Type Insp
Permit No.
Correction
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection RequeJ---
Re- Ins .Yi . e ❑
Name 9 /
Address / 3
Company
Phone #
For Inspector:
1
Approved
010-)-Ahr?
A Suburban Propane, L.P. Company
1491 N.E. 130th Street
North Miami, FL 33161
Dade 305-891-8393 • Broward 954. 923.6432
1 -888- GAS -4576
http: / /www.suburbanpropane.com
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GENERA
1. POOL
BEEN DE
2. ALL E(
EQUIPM'
PERMIT"
3.THEP
THE BA`
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 12/30/2002
Applicant: JEFFREY CHARLES
Owner: KELLUM
JOB ADDRESS: 453 NE 102
Contractor SUBURBAN PROPANE DBA ACME GAS
Local Phone: 305 - 891 -9353
Parcel # 1132060170810
Legal Description:
, - a0 b
/ 6�
Permit Status: APPROVED Permit Expiration: 6/28/2003
Work: RUN GAS LINES SET TANK TO FIREPLACE LOGS
This Permit is granted to the contractor or builder named above to cor
ordinances pertaining thereto and with the understanding that the work v
and approved by the proper municipal authorities. This Permit may be n
authorization. A further condi ' • n upon which this permit is granted is thi
ordinances and regulations . • rtaining to the work covered hereby wheth
by his agents, ants or ; ployees.
Sig
(INSPECT
In consi• ati•�of he issuance to me of this permit, I agree to perfon
with the plans, drawings, statements or specifications submitted to the E
myself, my agent, servants or employes.
/ Signed: (C(
Plumbing Permit
Permit Number: PL2002 -356
KELLUM
JEFFREY CHARLES
ST
Contractor's Address: 1491 NE 130 STREET
MIAMI SHORES SEC 4 AMD PLAT
Construction Value:
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.
JEFFREY CHARLES KELLUM
OR ROBERTA B. KELLUM
453 N.E. 102 ST.
MIAMI SHORES, FL 33138 -2452
Pay to the
Order of
Bank of America.
l �
ACH FUr 063100277
For
.•nr r •—• n.
P9 1
$200.00
Page 1 of 1
Date
1 re r' r. , r-1 r r ..•
PB 15 -14 LOT 19
Id v� 6 v
Total Fees: $10:00
Total Receipts: $0.00
+-r a 41.ar n..n horstfnr - in crrir)t. Cffmnliance with,all
3906
63 -4/630 FL
1348
Dollars 8"
BLK 92
A Suburban Propane, L.P. Compav
1491 N.E. 130th Street
North Miami, Fl_ 33161
Dade 305 - 891 -8393 - Broward 954 - 923.6432
1- 838 -GAS -4576
http://www.subuibanpropane.com
3L� LoitL 1.
6A5 mAx
/o 4'
1 -/53 NC /Ocg Mc 5/
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ELECTRICAL
TYPE:
Minimum Fee
QTY.
TYPE.
Dryer
QTY.
TYPE.
Outlet, Appliance
QTV.
TYPE.
Service Repair
QTY.
A/C Central 1 -3 Ton
Dryer Vents, Number of
Fan
Ventilation, Cost
Outlet, Wall
Ductwork, Cost of
Service, Temporary
Periodic Inspections
A/C Central 4 -7 Ton
Fire Sprinkler System
Fire Pump
Outlet, Switch
Fireplaces, Number of
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
1
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
1
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 QTY.
Minimum Fee
TVPE.
Condensate Drain
QTY. TYPE
Generator
QTY. TYPE. QTY.
Refrigeration, Tons
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wall/Win. 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
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
PLUNIBING
TYPE;
A/C Condensate
QTY.
TYPE
Drains, Roof
QTY.
'I'YPE,
Miscellaneous Fixture
QTY.
TYPE;
Soakage Pit
QTY.
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
1
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
1
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:
Page 4
OFFICE USE ONLY
CHECKLIST
0 OWNER - BUILDER FORM
(Attach)
• 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
m PROOF OF OWNERSHIP
(Attach)
• HRS / DERM APPROVAL
(Septic / Sewer)
® IMPACT FEE
(New Construction)
® OTHER
(Specify & Attach)
PERMIT FEES
(sq.ft. = x/1000
x ¢.60)
(0.005 /sq.ft.)
$ (¢.01 /sq.ft.)
REVIEWED AND PREPARED BY:
SECTION
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
BY
DATE
/34 -ti
PERMIT APPLICATION
m CONDO ASSOCIATION APPROVAL
(Attach)
BPR APPROVAL (Restaurants)
® CONTRACTOR REGISTRATION
(On File)
TOTAL $
ISSUING OFFICIAL
DATE:
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL c (305) 795 -2207 o FAX (305) 756 -8972 http : / /www.miamishoresvillage.com
Page 2
IN IPORTANT 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.
STATE O ORIDA, COUNTY OF MIAMI -DADE
SEAL:
Si gnature of Owner
'7 Print Name
Sworn to and subscri • s befo
2 04 11
at
Personally known //
i A7 Ct
COMMISSI•� ,
O da . +1 •_
q• MY COMMISSION EXPIRES
OF „ s q.
ner 11.2004
1
of Notary Public - State of Florida
OR, Produced Identification
STATE �JF IDA
of Contractor / Qualifier
Print Name
Sworn to and subscribed before me this AO
SEAL:
Joy o, F/6-z,os
PERMIT APPLICATION
Y OF MIAMI -DADE
day of N"
OFFlCWLNOTARY
at a of Notary Pu j A._
r
• w IIMGi.
f Q °11513MMISSION NUMBER
CC981872
- r� 0 MY COMMISSION EXPIRES
DEC.11,2004
Personally known OR, Produced Identification
Type of identification Produced: Type of Identification Produced:
CONTRACTO
New Construction
Name so b U/L 64,J
/0 11 /4/tJ
License No. 0// ?6
/
-..)
Address
��e /v41 /3 0 s
ia �!/4in+/ PL
Telephone 30 S cS / ? q
Fax.-10,;) f/ de s io
Qualifier Name
ENGINEER
New Construction
Name •
-..)
, hll AZ
License No.
Alteration Interior
Address.
„ , 1 ,- 7
Telephone
- - ✓
e e' „ _ , -
t ,
Fax
Other
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'l Attachment
Other
Add'l Detachment
Other
INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
Step 1.
X , Job Address:
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 submitted
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
Zip
Folio Number Description of Work J& //d 4f L / A /e( $'e L 1-91 AID'
Lot Block ¢D ,F/AR Pt /Pee 44554
Subdivision PB PG
Current Use of Property
Proposed Use of Property
Tenant Information
VS-3
Address
A/ n'
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
GX
Ro o
Fence
Other
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
PROPERTY OWNER
Name
Address
Home Telephone
Business Telephone
Fax
boa gort s
Apt. City State
PERMIT APPLICATION
Master Permit No.
Subsidiary Permit No.
Zoning Linear Feet
Square Feet
'K Value of Work &2o "g Bldg Value
Tax Assessed/Appraised Value
Units Floors
Flood Zone Base Floor Elev.