EL-11-612Miami 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 No.
rr.co_
Master Permit No. I 0 - �-
Permit Type: Electrical
OWNER: Name (Fee Simple Titleholder): �c) 1`Z J Phone #:
Address:
City: State: Zip:
Tenant/Lessee Name: Phone #:
Email:
l i s
JOB ADDRESS: k R )1/4) (-A) 1, 3� i
City: Miami Shores
Folio/Parcel #:
Is the Building Historically Designated: Yes NO Flood Zone:
County: Miami Dade Zip: 3 3 13E
CONTRACTOR: Company N fie: ) 1 et /4-r < </ 1146. Phone #: 7511 - 6 Z 74/6
Address: J a- 314 (Qv-) I `e 6a C-14.--
t ,
City: 4 rI. Ei. L tt/_i 1 (/ State: L Zip: 2y 9g.
Qualifier Name: .094212 9 i. f iC._ t .e C.4 ✓L1j Phone #: ,S%s iG z 711
State Certification or Registration #: F !$c 1/ 9 91 Certificate of Competency #:
Contact Phone #: 7 5Y00741 Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ S are/Linear Footage of Work:
Type of Work: DAddress DAlteration
Description of Work: L _) C.) (' C
(t� LC)lr2
New ORepair/Replace
ODemolition
* * * * * * *** ** ** * ** *** * **** r * ** * ** * * ** * * ** Fees************* ** * ** * * * * * * *** * * *** * * * * * * * * * ***
Submittal Fee $ Permit Fee $ / t' c" # 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 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.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this
day ofPt , 20 / (, by
who is personally known to me or who has produced
As identification and who did take an oath.
5
My Commission Ex
/efr 1 /1
APPROVED BY Plans Examiner
Signature
414r
Contractor
The foregoing instrument was acknowledged before me this 3
day of APZ. , 201( , by STAe--GC-tfc .
who is personally known to me or who has produced
as identification and who did take an oath.
Structural Review
(Revised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09)
NOTARY PUBLIC:
Sign:
Print:
My Commission
r+ • e,• J .
Expires ®�''a
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* * * * * **
Zoning
Clerk