EL-12-825 (2)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 No.
MMCMETE;
La MAY 092012
B Y: vm
Master Permit No.
Permit Type: Electrical yy, }
OWNER: Name (Fee Simple Titleholder): / D 171 U((�� Phone*
5402 c `))
City: ( State: zip: 33 /4
Tenant/Lessee Name: Phone#: 59
Address:
Email:
JOB ADDRESS: 3 GU 9 3 4 _SK.
City: Miami} Shores County: Miami Dade Zip: 3 3 %3e
Folio/Parcel #:
Is the Building Historically Designated: Yes NO `k Flood Zone:
CONTRACTOR: Company Name: NL°1Gc Phone#:
Address: "fc30 0 R.A■166 he , •
City:
Qualifier Name: IQ I Cailleb
State:
Zip:
Phone#: qS4-? 37'- Q893
State Certification or Registration #: '% I X 63 Certificate pf Competency #: 1 l6- 000 .:X...
2
Contact Phone#: 9 ° 96_ Email Address: [21 121c44410 c 6egs Wcic, G J-ft - GQiti
DESIGNER: Architect /Engineer: Phone#:
Value of Work for this Permit: $ r5'5) Square/Linear Footage of Work:
Type of Work: UAddress ❑Alteration
ONew ORepair/Replace
ODemolition
Description of Work: / Ill- 4.17 ,J 601F M 7L4 7
********* * * * * * * * * * * * *** * * * * * * ** * * * * * * * *F ************* * * ** * *** * * * * *** * * * * * * * * * * * * * ***
Submittal Fee $ Permit Fee $ 4.? CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Edueation 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 comme ' nt must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued In t ' rsence of such posted notice, the
inspection will ndit be proved and a reinspection fee will be charged.
The foregoing
day of
who is perso all
ki,
NOTARY PUB
Sign:
l'ti31f
er or Agent
as acknowledged before me this
201 -5 ; by �` �� ( i. n b ( _ ,
own to me or who has produced
As id- _, cation and who did tak an oath.
■
Signature
Contractor
The foreg J' ' g instrument was acknow ged before me _this
of , 20 S kby
who i
me or who has produced °°---
as identification and who did take an oath.
My Commission Exp
sett
Notary Public, State of Florida
Commission. EE 107498
My oomm. expires June 28, 2018
My Commission Expire
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APPROVED BY r .r d ' ,Y Plans Examiner
01SVER1
DD76896I `c
M 7_. _ -E 2012
Zoning
Structural Review Clerk
(Revised 07 /10/07)(Revised 06/10/2009)(Revised 3/15/09)