PL-07-2459n. \i1A -
'Lff4t1
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type: Plumbing
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Owner's Name (Fee Simple Titleholder) ` Phone # C.3c>5-) -
Owner's Address 92 `a 5 No
City�.�4� State C Zip
Tenant/Lessee Name Phone #
E- MAIL: j-2f � 2 Fc � 5 a , /r�r
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip
its DEC 0 7 2007
bt
BY:
Permit No. FLO-7' .2450f
Master Permit No. 6S l S ®�
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company Name
ibrvQ/ o
Phone #
Contractor's Address
City State
Qualifier Name
Zip
Phone #
State Certificate or Registration No. Certificate of Competency No.
E- MAIL:
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ 900
Square / Linear Footage Of Work:
Type of Work: ❑Addition El Alteration ['New
Describe Work: awc P x is t, r■S_ r LsLr
‹air /Replace
['Demolition
* * * * * * * ***** ** * * *x, ** ** ***************Fees************************
/5-°
4^
Submittal Fee $
Notary $ S-00
Scanning $ 500
Permit Fee $
Training /Education Fee $
Radon $ DPBR $
Bond $ Code Enforcement
* * * * * * * * * * * ** * * * * **
CCF $ �CO/CC
Technology Fee $. IJ
Structural Review. $
Double Fee $
DEC 13 07
CK 45
Zoning $
Total Fee Now Due $
See Reverse side -4
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
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
Signature
Contractor
The fore oing instrument was acknowledged befor me this The foregoing instrument was acknowledged before me this
day of � , 20 al by. 'Jam I Uk. (/� � , day of 20
.,� by
tee.
„s who is personally known to me or who has produced
s identification and who did take ti1o`L,�1
���'� �0 ylc• as identification and who did take an oath.
�SQ,� . �q `V„s'a'
�� .s%h, °� •
`04'4°4,6
al �„ .,�,. G° � Sign:
l�� <;' Print:
who is ersonally known to me or who has produced
�- „ -00, .,l .
NOTARY PUBLIC:
Sign:
Print:
NOTARY PUBLIC:
My Commission Expires:
* * *xxxxx *x * * * * * * * * ** * * * *dc
APPLICATION APPROVE
(Revised 02/08/06)
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My Commission Expires:
* *xx•xx *x* * * * * **** '. *********** x *** * * * **xx* ****aYaeaYreFxxxxx* *9:xxxxx
/at/or
Plans Examiner
Engineer
Zoning