EL-11-42ADT Always There°
ADT Security Services
Lic#: EF0001121
Request for Permit Cancellation
p (Form must be signed and notarized by owner or contractor)
Date: U /ll /� //
Request to cancel permit number: (� _ V.5
Reason for cancellation request:
V No Work Done (plans must be at job site)
Work Removed (plans must be at job site)
_Exempt from Permit
_Superseded by Another Permit Other Permit Number
Of superseded, plans for permit being cancelled and plans for permit that is being superseded by are required with your request).
_Duplicated
Customer Name:
Customer Addr.
State:
Other Permit Number
(for m g purposes)
�y�
. /d -oe //" g'/i� City: e
Zip: 33/3J7
Customer Telephone Number:
Customer E -Mail Address:
Person requesting cancellation is: _Property Owner _Contractor
Hired Agent for _Property
Customer's Signature:
STATE OF FLORIDA COUNTY OF MIAM1,- DD�i
Sworn to and subs bed before e this / T�
day of , 20//
by
Signature of Notary Public if
Print Name a
(SEAL)
Personally known
or Produced Identification
Contractor
Print Name:
atP" °e;a� ALBA H. AQUILA
Notary Public - State of Florida
My Comm. Expires Jul 26, 2015
Commission # EE 106656
- FOR OFFICE USE ONLY -
For permits that are superseded by another permit the plans have been: Received Not Required Pending
Process Number Issued:
Request Received by. Title:
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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
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: Electrical
Permit No. El 11 �' f
Master Permit No.
OWNER: Name (Fee Simple Titleholder): % Phone#:
Address: 43).--A0 ' e'
City: 0"e'S
State:
Zip:
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: / 614-41, )
City:
Folio/Parcel #:
Miami Shores County: Miami Dade
Is the Building Historically Designated: Yes
CONTRACTOR: Company Name:
Address:
Zip: 33i,.0
Flood Zone:
r/art �
.i ✓ Ph 7(12 °`57/c
D 9L3 ,.,11/ t 14/
City: fret State:
Qualifier Name:
State Certificatio or stration #: f'�' ® ®/% Certificate
Contact Phone.143 1 Vtt Email Address:
DESIGNER: Architect/Engineer:
Zip:
Phone
of Competency #:
Phone#:
Value of Work for this Permit: $ / �� �— Square/Linear Footage of Work:
Type of Work: ❑Address QAlJei% . n New ❑Repair/Replace
Description of Wor fj d — -
(7) e
(9)
❑Demolition
**+ ** tie *** * * * ** * * * * ***** ** **** ***** ***ri Fees""' °` ****43** *** * * * * * * * * *** **** *Ole* * * **** **
Submittal Fee $ Permit Fee $ e
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
i
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $
•
Bonding Company's Name (if applicable)
Bonding Company's Address
State Zip
a,
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
City
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 FT.F.CTRICAL 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 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 <sence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature,
Owner or Age
The fore ing instrument was acknowledged before me
day of , 204, by ;
who is :ersonally known to me or who has produce J/°
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: �dfr, ,
My Commission Expires:
********** **************-. ,. **
APPROVED BY
2011
co.,
Contractor
The foreg • g instrument was acknowledged before me this 7 ‘, wrtV
day of , 2(1L_, by
who is p r orally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
! ?iORIDA
..2330
°011
�iOP•G: 'I ; ?U .;000O.,INC,
***************************** ***************************** ** ***********rya*******
Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Zoning
Clerk