MC-10-911BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: MECHANICAL
Owner's Name (Fee Simple Titleholder) Uql2.1 t4 A, CiGg„& E. Phone # u 7 - 5)' 1
Owner's Address 4 01 +41 me Ste.f-
City Nth SVious State F1... Zip 33 13??
Tenant/Lessee Name Phone #
Email
s yah tarn
Job Address (where the work is being done) 40 (4 E wart sift ti
City Miami Shores Village County Miami -Dade Zip 3313
FOLIO / PARCEL # 11 2.2.3 10 15a 13Q
Is Building Historically Designated YES NO, V ** - ** Flood Zone
Contractor's Company Name j (7 /(/J6 P f�c7 1 %4 one # 3tZ - `� 99 - 900 0 0 6
Contractor's Address 710 7 .ti a.; '7 $ f
Cit M L 4-yo / /-- State F Zip ,....a.3 l /
6 6
Qualifier Name �L '4 (� A 4 Phone # 3 O5 W �
� . �t, 'i .��
a ' 0 06
State Certificate or Registration No.
Contact Phone 3 ' 7
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ 3,50 Square / Linear Footage Of Work:
Type of Work: ['Addition ❑Alteration LIew ❑ Repair/Replace � ❑ Demolition
Describe Work: �P15"C l I Wel6I.1 Ric" Q AM 6,F. �id is (`
dd ( VI +rhe,'
v►�1 {�rnni+t 4 Rc -11 - Mot
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Submittal Fee $ y ✓ ryt.e)c) Permit Fee $
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
E -mail
Scanning $ 4tY W Radon $ DPBR $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $
Bond $
See Reverse side -* /.6
MAY 2 1 2010
Permit No. MC - 10 -
Master Permit No. RC -1\ —0 ° I — Vg
Certificate of Competency No.
per‹ evz/(274 �d
/,,
******** * * * * * * * * * * * * * * *** * * * * * * * * * * * * ** F * * * * * * *** * * ** ** * * * * * * * * * * * * * * **
6 -D t 0 6 CCF $ (,'CJ's J CO /CC $
Notary $ Training/Education Fee $ U ' A o Technology Fee $ �� • W
114-(00
\.,
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 COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with a estz '`value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and con ct tJ n law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the r L ce of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the b i erz is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be - ha
Signature
Sign:
Print:
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this MI The foregoing instrument was acknowledged before me this 0?
Ail
d. _ _ , i i a.f/ _ _
who is personally known to me or who has produced who is personally known to me or who has produced
as identification and who did take an oath.
NOTAR ' UBLIC:
My Commission Expires:
A. identification and who did take an oath.
F. Sts c..
(Revised 07 /10 /07)(Revised 06/10/2009)
ti ,
07 /02/2010 d
C
9• . D05i997 Q,
rinn
Engineer
Signature
7 1e4:-el—d) �
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * *� * * * * * * * * * ** * * * * * * * * * * * * **
APPROVED BY Pl'a31� Examiner
1/04/04
EDITH F. NOVOA
Notary Public, State of Florida
*Seth { #0199 S * * * * * **
My 0emrfl68lan Expires Apr. 16, 2012
Zoning
Clerk checked