PL-10-187611 -)24ao
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 ype: PLUMBING
Owner's Na ; ee Simple Titleholder
Owner's 'Address `.` d Ei Ci I 61- Th riacp,
City .--4 L( L iTh 6Iiirt State 0
Tenant/Lessee Name
'5i .0 (c imLc
Email
loammy2
a OCT 252010
Permit No. P.\ I0— l&1
Master Permit No.
Phone # -icy' - € C l
Zip
Job Address (where the work is being done)
City Miami Shores Villa e
FOLIO / PARCEL # l H3 C
33
Phone #
)T e C[ t 51- TerrC-eo
County Miami -Dade
0
Zip
Is Building Historically Designated YES
Flood Zone
Contractor's Company Name C.x60 A) c)C3 c)(..76L6
Contractor's Address 19 3_3 M 0/ 1k(7 c)r
City Q kyt (`,H E9 C 0-1 State FL_
Qualifier Name
k/V rk-
%7 "1 0.5
Zip 33(0�04
Phone # t `��; T �7
State Certificate or Registration No. C f C-- icks7011 Certificate of Competency No.
Contact Phone " P IS C a (04 "t . �. E -mail TVA" i C= W1 k C� .e pc) 011 e t 15o , Ae0 1--
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $ l SO
Type of Work: ['Addition Alteration
Describe -Work:
Square / Linear o�' -'`e Of Work:
Daew
cx t & •pr
0 Repair/Replace ❑ Demolition
Submittal Fee $
**** ** * * ** *** * * * **** *** * * * * * * * * * * ** Fees* * * * *x*** * ** * * * ** * * ** * * * * * ** * * ** * ** *** ** ***
5D .) Permit Fee $ CCF $
Notary $ Training/Education Fee $
Scanning $ Radon $ DPBR $
Double Fee $ Violation date:
Structural Review. $
CO /CC $
Technology Fee $
Bond $
Total Fee Now Due $
See Reverse side -*
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 buildi k is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be ch ',; e
Signature
weer or
The foregoing instrument was ackn edged before me this
day of 04,71_ , 20, bye .s5` . Pact rAC,c)
who is personally known to me or who has produced
As i enti cat�b�n and who did take an oath.
CARS ASS
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of C) c/t- ,201O,by i`` St f-
who is personally known to me or who has produced
NOTARY PUBL
Sign:
Print:
My Commission Expires:
egtko
COMMISSIONifiglia
EXPIRES: 4M 24, 201
rtS s
Blinded IhmdM er
Sign:
APPROVED BY
Plans Examiner
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
as identification and who did take an oath.
i8OB ;N,E HUG
Wary Pubic', State of F'b j
commission
My Commission Expir
* **
Zoning
Clerk checked