PL-11-1392Miami 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: PLUMBING
Permit No.
AUG 0 2 2011
BY:
11)N1
Master Permit No.8Pr 11 �� I
OWNER: Name (Fee Simple Titleholder): ate 1 1i (aV1. C o Phone#: 1813 7 `{ " 6 I 1
p
Address: p? 1 S u ts-ek
City: h, r ∎ 5- -- State: Zip:
Tenant/Lesse- Name: Phone#:
Email: 'a sot[ e
o(QINco c'o
JOB ADDRESS: i 4 € aI 1 S+
City: Miami Shores
Folio/Parcel#: t 3 2 S ~0 o f c
Is the Building Historically Designated: Yes
CONTRACTOR: Company Name: - (
Address: �q u, L�
City: L IS 1 State: L
Qualifier Name: 111117, 'S
State Certification or Registration #: 1°°�
Contact Phone#: Email Address: bri
ounty:
t G� In'%.
TQrre—Lg.--
Miami Dade
Zip: 33 t 3 $'
Phone #:
zip: L
Phone#( ip•5 ?..3
Certificate of Competency #:
0,Ckrq
Phone#:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $
Type of Work: DAddress
Description of Work•.
ear Footage of Work
DRepair/Replace
DDemolition
** ******** **** * * ** x ***** x*+xw********** *Fees** ** a ***** ** *** *** ****** **
* * * * * * * * * * * * * * * **
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 $
ding 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, BOILF.RS, 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 WITII 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certi ipy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days t uilding permit is issued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee
Signature
The fo .. o
day of
who is pe
Owner or Agent
trument was acknowledged befor me this
0 9 The foregoin
20 _, by 9 cj/ ,/¢'/�%C �'f , day o
own to me or who hbs produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission
EXPIRES: Amway 23, 2013
i fl. Nagy Diwoant M$OC. C
1400-3-NOTARY
Contr*{ct
as acknowledged before me this
by
rite,
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
****** * * ** b4 *k**#******dWN***4*4******* #*i **# ***********i#*** it.***** pis**8+ T<+ k******* ********** # **************4****
APPROVED BY Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10i2009)(Revised 3/15/09)
Zoning
Clerk
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