EL-12-550Miami 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
Permit No. EL« 1 Z -55
Master Permit No. ?L12 '� �M'i
BUILDING
PERMIT APPLICATION
FBC 20 10
Permit Type: Electrical
OWNER: Name (Fee Simple Titleholder):
Address: /4 3 /u kJ / 5- 74.49e i F
City: /*,- ,5 .4l e ,$ State:
I VED
MAR 30Z 1Z
Phone #:
zip: 33/6/
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS:
/6 3 iV& /00 ateeet
City: Miami Shores
Folio/Parcel #:
County:
Miami Dade Zip:
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company Name: X i7e*I6F1C0#4=a/ r /c7,z/cstt c°4fore.Ae3 €f Pie Phone #:X 7P6 Z73 662. -
Address:77151n i 5a) 51 TFe.
City: 1°6`-1 / State: FL- Zip: 3.34 q' 3
Qualifier Name: -')5 s---. /°/ (..9/Jt) z Phone #: 786 273 6 02J-
State Certification or Registration #: Ff d 3C' 1 c 6- 8 Certificate Jof Competency #: r��� �'�
Contact Phone#: lQ 6 2 3 3 06 Z) Email Address: 6' � . c/ e l CC` /coo /re: G(4, ij ' i i c y a ° ` E° 0,1
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ e Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration y ❑New pair/Replace ❑Demolition
Pte
Description of Work: 74' ')"** ?' 1? . '�.
J
**** *+ x**** ** a: *x*w******* **** * ********** Fees**** *+ x+ x***********+ x+ x**** **********s :** *******
Submittal Fee $ 50 ' #�.1? Permit Fee $ /e,' G� G i� CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 561 eC
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
1 �
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 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 properly 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 Signature
Owner or Agent
The foregoing instrument was acknowledged before e this 22.
day of I-t..re. , 20 2., by
who is personally known to me or w o has produced �/
J.
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Co
Contractor
The foregoing instrument was acknowledged before me this Z2
day of if , 20 2 -by
V '
who is personally known to me or who has produced P/
!� L as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Comm
Z04Zt133UISSPWO31W . 7G
on Expires: o0811d sal r •
BPtmH W aw*S Moll L1MN
* * * * * * * * * * * * * * * * * * * * * * * *. ***************************************************** ***: **** ***** * ** *** * * * ** *******
APPROVED BY
/#7 . 2- Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
PRIOR TO INS 11'N OF HOUGH
ELEl.1 ,IC 16I ;iN3
CHECK NAM tPLA1E DMA OF A/C
EQUIPMENT, HOT WATtR HEATERS
AND OTHER EQUIPMEN I 10 OBTAIN
CORRECT WIRE SIZES AND
OVERCURRENT PROTECTION.
ADEQUATE SERVICE CAPACITY
tIALISV Et PIOVIDED.
SUBJECT Tc, L Lt : 1 a CAL
INSPECT'ON
Zoning
Clerk