EL-11-1762Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 169082 Permit Number: EL -9 -11 -1762
Scheduled Inspection Date: February 27, 2012
Inspector: Devaney, Michael
Owner: INC, NICAMERICAN
Job Address: 1360 NE 103 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: PINAR ELECTRIC MD INC
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132050300070
Phone: (786)256 -0812
Building Department Comments
ELECTRICAL WORK FOR INTERIOR REMODEL
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
CREATED AS REINSPECTION FOR INSP- 169031. CREATED AS
REINSPECTION FOR INSP- 164835. Service not completed.
F P & L notified of a work with.
February 24, 2012
For Inspections please call: (305)762 -4949
Page 19 of 43
44 2 0
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 T
Electrical
OWNER: Name
Address:
City: 9y /'Il
imp
e Titleholder
i
1/4V60 0n11
JP I
SEP 2 6: 2011
V
11 Iro2.,
Master Permit No. a.- // - 68,
Phone #: ' e`j',3 3v 6
State:
Zip: �/
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: /3,60 J / 51r-ow-
City: Miami Shores County: Miami Dade Zip:j/
Folio/Parcel #: // ^ )Z25. 69 —49:2 O
Is the Building Historically Designated: Yes NO
Flood Zone:i
CONTRACTOR: Company Name: /!thnt.. aG'27U 4e2 % Phone #: '7/I Zg (51/Zs
Address: j/-9/0 Iihte /Z "z '; 02. /
City: Z]do'r -oC2i State: Zip: 3 3/ 2,
Qualifier Name: irjit/ a OA-7h' (� Phone #: 7/ 2-6 eb'/
State Certification or Registry' n #: ( /e. „ ,.., O . Certificate of Competency #: 0 36— 006/0
Contact Phone #: " r9ij LP C)1/ Email Address %/4/J9X."A C3 � /gairt,a ' °A/er
DESIGNER: Architect/Engineer: I r 49 Phone #: qg6 Z17 7
Value of Work for this Permit: $ Z/a95. 17 S + ar ear Footage of Work: 3/
Type of Work: OAddressY C 1Alteration n , ewZepair%Replace UDemolition
1\) Description of Work: -`e ' f' 4':.?
***************************************Fees****************** * ** * * * * * * * * * * * * * * **
Permit Fee $ % � may' CCF $ CO /CC $
Radon Fee $ DBPR $ Bond $
Submittal Fee $
Scanning Fee $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
) 91771?)
TOTAL FEE NOW DUE $
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 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 approved and a reinspection fee will be charged.
Owner or Agent Contractor
ledged befog me thiaU The foregoing instruume�nt,was �acknowledged before me this
10 .% .f �``/` , day of l c?"��2U by /44 Z O Q751 ,
own to me or who has produced we who is personally known to me or who has produced3O
identification and who did take an oath. Ci 7$22C? as identification and, ho did take an oath.
NOTARY PUBLIC:
The foregoing instrument as ackn
day o .�.� , 20 1� •
b ��
ho is
Sii
pally
NOT Y P BLIC:
Sign: 4v/I
ki
Print:
My Commission Expires:
APPROVED BY
Sign:
Print:
_.,_.__ „._ , .. 14
._ .•
., #DD91 _V"r_
My Commis,�i� 3453
fCed flp � 11 -17- 3
Atlantic Co. Ira,
3roY****9:9r3:*: *** * * * ** Y* Y***: Y: Y***# ***&seaY*** ************* Y**sY***:Y**** Y**** Y
lb SP/7Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07XRevised 06 /10/2009XRevised 3/15/09)
MIAMI -DADE COUNTY
TAX COLLECTOR
140 W. FLAGLER ST.
1st FLOOR
MIAMI, FL 33130
CTQB
Construction Trades Qualifying Board
BUSINESS CERTIFICATE OF COMPETENCY
03E000610
PINAR ELECTRIC MD INC
D.B.A.:
ORTA AfQDRES
Is certified under the provisions of Chapter 10 of Miami -Dade County
Vii! D,LB GN' ,a llt t 3 L2t Y
2011 MUNICIPAL CONTRACTOR'S 2012
TAX RECEIPT
MIAMI -DADE COUNTY - STATE OF FLORIDA
PURSUANT TO COUNTY CODE SEC. 10 -24
EXPIRES SEPT. 30. 2012
RECEIPT NO 30- 5354774
BUSINESS NAME / LOCATION
PINAR ELECTRIC MD INC
4910 NW 102 AVE
OWNER :PINAR ELECTRIC MD INC
THIS IS NOT A BILL - DO NOT PAY
CC NO: 03E000610
SEE BACK OF RECEIPT FOR
A LIST OF NON- PARTICIPATING
MUNICIPALITIES
Receipt holder must
register in the city
where work is to be
done.
PAYMENT RECEIVED
MIAMI -DADE COUNTY TAX
COLL047119 / 2 011
02290002002
000200.00
MIAMI -DADE COUNTY
TAX COLLECTOR
140 W. FLAGLER ST.
1st FLOOR
MIAMI, FL 33130
512580 -2
BUSINESS NAME / LOCATION
PINAR ELECTRIC MD INC
4910 NW 102 AVE
33178 DORAL
FIRST -CLASS
U.S. POSTAGE
PAID
MIAMI, FL
PERMIT NO. 231
RECEIPT HOLDER MAY DO
BUSINESS AS A CONTRACTOR
AS SPECIFIED HEREON
ELECTRICAL CONTRACTOR
DO NOT FORWARD
PINAR ELECTRIC MD INC
ANDRES ORTA PRES
4910 NW 102 AVE #102
DORAL FL 33178
7
1 i!11111 11111!111 1,1 1,1∎1111111 i1111),),111
11
2011 LOCAL BUSINESS TAX RECEIPT 2012
MIAMI -DADE COUNTY - STATE OF FLORIDA
EXPIRES SEPT. 30, 2012
MUST BE DISPLAYED AT PLACE OF BUSINESS
PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10
;11
OWNER
PINAR ELECTRIC MD INC
Sec. Tye of Business
196 ELECTRICAL CONTRACTOR
THIS IS ONLY A LOCAL
BUSINESS TAX RECEIPT. IT
DOES NOT PERMIT THE
HOLDER TO VIOLATE ANY
EXISTING REGULATORY OR
ZONING LAWS OF THE
COUNTY OR CITIES. NOR
DOES IT EXEMPT THE
HOLDER FROM ANY OTHER
PERMIT OR LICENSE
REQUIRED BY LAW. THIS IS
NOT A CERTIFICATION OF
THE HOLDER'S QUALIFICA-
TIONS.
PAYMENT RECEIVED
MIAMI.DADE COUNTY TAX
COLLECTOR:
09/19/2011
FIRST -CLASS
U.S. POSTAGE
PAID
MIAMI, FL
PERMIT NO. 231
N:.; I PP.`•
RENEWAL
RECEIPT NO. 535477 -4
CC # 03E000610
102
WORKER /S
2
DO NOT FORWARD
PINAR ELECTRIC MD INC
ANDRES ORTA PRES
4910 NW 102 AVE #102
DORAL FL 33178
OCT -12 -2011 12:29P FROM:PINAR ELECTRIC MD IN 3059947957
•
TO:3057568972
P.1
qtr CERTIFICATE OF LIABILITY INSURANCE I
DA 0`21111
PRODUCER excestice In9 am:a Agana/
3801 SW 107 Avenue
Mia ml. FL MISS
Phone 0900 Fax (308)2283997
MIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND =JEERS t40 RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND
ALTER THE COVERAGE AFFORDS° e' P.M POLtG
OR
$ BELOW.
INSURERS AFFORDING COVERAGE
NAIL` #
Pinar � � MD
INSURED 4910 N W 102 A v e # 102
Dorsi. FL 33178,
i 1
!mum A; GRANADA INSURANCE COMPANY
INSURER a; ASCENDANT COMMERCIAL INSINC
INSURER Ci_
tNBURF.Rq:
INSURER E:
COVERAGES
INSURER la;
THE POLICES OF INSURANCE LISTED HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY GE ISSUED OR
MAY PERTAIN. ME MBURANCEAFFORDED 9Y THE POLICIE8 OESCRISED HEREIN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COMMONS OP SUCH
POUGIEE. AGGREGATE LIMITS bNOWN MAT NAVE BEEN REDUGE_R BY PAID GLAtIME.
OR MIRO
TYPE OP INSURANCE
GENERAL LIABILITY
POLICY NUMEEq
FAUX( t [ WltDeUcITYlYvI e
08/09/1 1
FaV6CY 1> EVIRATION
WaONY}
LIITr8
EACH OCCURRENCE
1,000 000
A
a
®OOuIMHRC1At GENERAL tlA8dLT1Y 0185FL00001837.0
: ❑ CLAIMS MADE ❑ OCCUR
08(09/12
oouaalDAMAGE TO RENTED
PREMISES Ma ac
60,OQ0
MED P (An one perm)
1,000
❑
t3EWLAGGREGATE
®
PERSONAL a Aov INJURY
1,000,000
GENERAL AGGREGATE
1,000,000
UMTTAPPLES PER:
PRODUCTS - COMP/OPAo0 1,000,00Q
POLICY • PROJECT ❑ LOC
$500 Dad Propbamage
i
❑
AUTOMOBILELIABLrrY
■ ANYAUTO
• ALL OWNED AUTras
❑ SCHEDULED AUTOS
'
COMBINED SINQI.E LIMIT
(Ea atcrldelt)
BODILY INJURY
par n
❑ HIREDAUT'OJ
❑ NONOWNEDAUTO9
ilODU.Y INJ URY
(Peratx{dett$
PROPERTY CAMACE
(Per saidenS
n
aARAGE LIABILITY
AUTO ONLY- EA ACCIDENT
❑
• ANY AUTO
OTNwnT'NAN BAACC
❑
AUTO OILY: AOct
❑
TOWESSAIIIIIRELIA LIABILITY
0 OCCUR ❑ CLAIMS MADE
EACH OCCURRENCE
AGGREGATE
❑ DEDUCTIBLE
'WORKERS
❑ RETENTION $
_.._
B
COMMFENSAT10NAile
EMPLOYERS* LABILITY
• ANY PROPRIETOR, / PARTNER / EXIyCUTNE
WC 2714 -0 11/13/10
11115111
��tyRYtJMITS ❑
EL..EACHACCIDENT 1 MOOD
OFFICER /MEMBER EXCLUDED?
If YE,1 dabs
el, DISEASE • EA ENFLQYEE
110001000
9PMICUV. PRCti� below
E.L. DISEASE - POLICY UNIT*
.1 .000.000
OTHER
DESORIPiloN OP OPERATIONS / II.00ATi0ND I VEHICLES /EXCLUSIONS ADDED ay ENm:40E1/ENT/ SPECIAL PROVISIONS
Certificate for Pinar Electric MD Electrical Contractors
CERt1FICATt• HOLDER
CANCEI.0 ►TION
Miami Shores Villa G
Building Department
10050 NorkhEest 2nd Ave
Mlaml Shores Florida
'305. 758 -8972
ACORD 2$ (2001108) OF
OHOUTA ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BHFORN TRH
EXPIRATION GATE THEREOF, THS ISSUING INSURER WILL ENDEAVOR TO MAIL
$0 DAYS WRTITEN NOTICE TO THE 8TIRTIFICAT C MOLDER NAMED TO
vu-awr,evr PMUJRe To co so SHALL IMPOSE NO OBLIGATION OR L ABRJTY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATR1E
U! sluing! a3uU Hein nusit 83X
OACORO CORPORATION 1888
1VLS:11 l lOZ 71 120
OCT -12 -2011 12:29P FROM:PINAR ELECTRIC MD IN 3059947957
TO:3057568972 P.2
ed.be;A
'LT4jor t , {v ► ^:
E *p. 'at:3011 }" �`s$#1
IRE IZRENANDa ;,11.gt
riflamoit
• PORK.;
1
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Parcel Number
Expiration: 04/03/2012
Applicant
1360 NE 103 Street
Miami Shores, FL 33138-
1132050300070
Block: Lot:
NICAMERICAN INC
Owner Information
Address
Phone
Cell
NICAMERICAN INC
150 SE 2 Avenue
MIAMI FL 33131-
i
150 SE 2 Avenue
MIAMI FL 33131-
Contractor(s)
PINAR ELECTRIC MD INC
Phone Cell Phone
(786)256 -0812
Valuation:
Total Sq Feet:
$ 22,095.00
3450
1
Type of Work: ELECTRICAL
Additional Info: INTERIOR REMODEL
Classification: Residential
Scanning: 2
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$13.80
$11.60
$11.60
$4.60
$773.33
$6.00
$18.40
$839.33
Pay Date Pay Type
Invoice # EL -9 -11 -42120
09/26/2011 Credit Card
10/06/2011 Check #: 102
Amt Paid Amt Due
$ 50.00 $ 789.33
$ 789.33 $ 0.00
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Underground
W. W.
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL, PLUMBING, MECHANICAL WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS 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. Futhermore, I authorize the above -named contractor to do the work stated.
October 06, 2011
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
Date
October 06, 2011
1
1
Protect Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Parcel Number
Expiration: 04/03/2012
Applicant
1360 NE 103 Street
Miami Shores, FL 33138-
1132050300070
Block: Lot:
NICAMERICAN INC
Owner Information
Address
Phone
Cell
NICAMERICAN INC
150 SE 2 Avenue
MIAMI FL 33131-
I
150 SE 2 Avenue
MIAMI FL 33131-
Contractor(s)
PINAR ELECTRIC MD INC
Phone
(786)256 -0812
Cell Phone
Valuation:
Total Sq Feet:
$ 22,095.00
3450
1
Type of Work: ELECTRICAL
Additional Info: INTERIOR REMODEL
Classification: Residential
Scanning: 2
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$13.80
$11.60
$11.60
$4.60
$773.33
$6.00
$18.40
$839.33
Pay Date Pay Type
Invoice # EL- 9- 11-42120
09/26/2011 Credit Card
10/06/2011 Check #: 102
Amt Paid Amt Due
$ 50.00 $ 789.33
$ 789.33 $ 0.00
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Underground
W. W.
Applicant Copy
For Inspections, Call (305) 762 -4949 or Log on at https : / /bldg.miamishoresvillage.com /cap /.
Requests must be received by 3 pm for following day inspections.
NOTICE: In addition to the requirements of this penult, there may be AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER
additional restrictions applicable to this property that may be found in GOVERNMENTAL ENTITIES SUCH AS WATER MANAGEMENT
the public records of this county. DISTRICTS, STATE AGENCIES, OR FEDERAL AGENCIES.
October 06, 2011
2
��- '2// )74A.
R(. Ali mY1.
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.
No 1
8
-----
Master Permit No.� 11— 1 )8
OWNER: Name (Fee Simple Titleholder): P 14. A rte," � L) Phone #:
Address: 1 31,0 N ��, 103 �o
City: 1 ) A?») 1 State: Zip:
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: 3 l0 D )4
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #:
Is the Building Historically Designated: Yes NO �—
CONTRACTOR: Company Name:
Address: / /o / L) )D
City:_ 44 L. n
Qualifier Name: ,an, !'Y/'. e 1
A�6%A.7L. «66z1 ! i' ®� /
4Zt4 o ` e)r
State: TZ
Flood Zone:
Phone #:
Zipz, 99 7�
Phone ^
State Certification or Registration #08 E c�4i/ z7 Certificate of Competency #:
Contact Phone #: " �i Email Addres i�+a �, G-r �+! x11
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑Addre
Description of Work:
A
❑Alteration �l ❑New
V1cgVz' _9i, i5
❑Repair/Replace ❑Demolition
* *** * *** x******* ***** ***+r************ ** Fees+ a+ x*****+ x**+ x* ****+ x****+ r **** **a:a:*x:************
Submittal Fee $ Permit Fee $ >' CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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 At F 1DA VIT: 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Owner or Agent
The foregoing instrument was acknowledged before me this
day of , 20 _, by 1 / t h'Zli (8 1� /�Ai l
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of 20 1,\_, by AevIre3 L or a
who is : sonally known to or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Le
11
INIMM
.0001I 4111,-
rte.
My Commissi
a$ a$ sksksRj kiksksIasIadadcse*akyFYFikak *** . ,.. clads ******ak ******M**** is*S:: k*ek9ssk*dssk**ds*************—
APPROVED BY
Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
x..: BIBIANA VILLAZON
:4 MY COMMIS910N # DD 705397
—; EXPIRES: November 22, 2011
Rp +ps, Bonded Thru Notary public Underwriters
0**
Zoning
Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Permit No. Al // _ 1 ��
Job Name 4" le ke
CRITIQUE SHEET
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
Permit No.
BUILDING
PERMIT APPLICATION
FBC 20
II-15169
Master Permit No.
Permit Type: BUILDING pROOFIN
OWNER: Name ee Simple Titleholde +� � � Phone #:
t3.451•D (93
Address: 1 I
City: t . . . ,. �� t . State: c* J Zip: ��
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS:
I aC90 NF__
City: Miami Shores County: Miami Dade
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company Name: ti , T2 r [ .o»/ S 7l1Nc 7 , o+✓ .c e9-vi Ge? Phone #:
Address: 6®C5 NW /67 sL. 3-!/
City: /1 I A-1.1. I State: F L Zip: 3 3 /5
Qualifier Name: R i LA-1?. D..o ,j`? , rR-+ Phone#:
State Certification or Registration #: C F 1 i Z i g 1 Certificate of Competency #:
Contact Phone#: C3 o5) 3 Y 5 -11 i i 1 Email Address: n f o t ca� c( c- Se ✓ V I cescoep.covv,
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $
Type of Work: ❑Addition
Description of Work: Z .VISV
Squ e/Linear Footage of Work:
ONe Repair/Replace ODemolition
F
A)br ' ; ,�" � 1Ve (z) u&wars-
*e *e *ir # * * *****m******* ****Fees **+x**** * ***** ** * *e *e
Submittal Fee t . " Permit Fee $ ?c4' ;.CCF $ COI $
Scanning F
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $ Z4 0 a b®
Radon Fee $ DBPR $ Bond $
TOTAL FEE NOW DUE $ 11 -
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, BOIT,ERS, 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 absence of such posted notice, the
inspection will not be approv a • a reinspection fee will be charged.
Signature Signature
Owner or Agent
The fore � � ing ', � trument was ackno �l� edged beft�m e thi
, 20 Il , by I Y(�ll j�A�
l ho i. pp�ersoonally kno t me or who has produced !e
—I ,3- ntification and who did take an oath.
day of
3
AA
Contractor
The foregoing �instrgment was acknowledged before mite this 0 - f
day of e" , 20 R by J t 4' C) J &O it • D.1h.1`r.
t
_who is personally known tto eerQwJho l)5 produced ■)
5,3 _ a c as Idc cation and who did take an oath.
NOT Y PUB
NOT r ' PUBLIC: , -
Sign:
Print:
My Commission Expir
APPROVED BY ✓ /7/ ?// Plans Examiner
____J/ _ Structural Review
(Revised 07 /10/07)(Revised 06 /10/2009)(Revised 3/15/09)
Sign;
Pri
My mmission Ex
* * * * * * * * * * * * * * * **
Zoning
Clerk