ELC-12-108Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 169058 Permit Number: ELC -1 -12 -108
Scheduled Inspection Date: January 27, 2012
Inspector: Devaney, Michael
Owner: CHURCH, ST ROSE OF LIMA CATHOLIC
Job Address: 415 NE 105 Street
Miami Shores, FL
Project: <NONE>
Contractor: MOODY ELECTRIC INC
Permit Type: Electrical - Commercial
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)758 -0539
Parcel Number 1122310430010
Phone: (305)758 -2000
Building Department Comments
TEMPOARY HOOK UP OF ELECTRICAL FOR 16
CARNIVAL TENTS
Passed
121
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
January 26, 2012
For Inspections please call: (305)762-4949
Page 11 of 17
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
OWNER: Name (Fee Simple Titleholder):
Address: L/ % Ji C
City: ) A l S si n fi-s
Permit No.
JAN 2 3GL
Master Permit No.
i. a� 6= L 1 NA A Phone#:
3w
State: /
Zip: 33 i 3
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS:
City:
Folio/Parcel #:
Miami Shores
Ne° IOs s a
County: Miami Dade
Zip: 3
Is the Building Historically Designated: Yes
NO Flood Zone:
39
CONTRACTOR: Company Name: rn Or) rtg 1' c c -ra a ? ®R[ . Phone #: 3 o 72 ® Zoos
Address: b, L 9 Al 0 S red i
City: 14 ill l State:
Qualifier Name: trr as r, ' �e
State Certification or Registration # ®: Eao®� // 99 Certificate of Competency #:
Contact Phone#: I'd $ 7�® c'CD® Email Address: '1�t7 % /2J e Ago e m cody-1
A,04.
Zip:
Phone #:
_33/ 0
DESIGNER: Architect/Engineer:
ztg
Phone#:
Value of Work for this Permit: $ RD . 00 Square/Linear Footage of Work:
Type of Work: ❑Address OAlteration ONew CIRepair/Replace ODemolition
Description of Work: `r, ?t P c a^. 1 /lc c OP or E e- E-C n,z t e-4 4 wag
.A-92.r I e%1 14 C 1" r
* ** * ** * * ** * * * ** �xa�a��xa� *x�x�>kx�+x *�x�x�x�x�xx�� * ** Fees************ �x* �x�xx��ua��r�x+ x+x *�x�x�x** ** * *** * ****�xa�+xx�
Submittal Fee Permit Fee $ /0426, s e" P CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ / (gab' 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
A
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 CONDMONERS, 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 absence of such posted notice, the
inspection will not be approve. and a reinspection fee will be charged. j
Signatu G Al"
Owner or Agent }�
The fore oing instrument was ac��kknppow g° before me this tU
d y of (%1V1 , 20 �a, , by t-tl` + ,
°vho is personally known to me or who has produced
As identification an . who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
1 1' • -7' 1-111'71'
*** * * * * * *** * * *** * * * * * **
APPROVED BY
Si
Contracto
The foregoing instrument was acknowledged before me this 29
-
day of %J 20 L by O h a' 1�1 Q(;
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
MARY PATBRIGGS
et; MY COMMISSION # DD 979267
EXPIRES: May 11, 2014
Bonded Thru Notary Public Unde wrtters
Zoning
Clerk