EL-11-633bit Miami Shores Village
g
Building Department
BUILDING
PERMIT APPLICATION
FBC 20
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972,
INSPECTION'S PHONE-NUMBER: 03Q5).764.4949
Permit No. )1 - (0'53
Permit Type: ELECTRICAL
Owner's Name (Fe- Simple Title older) L
Owne 's Address
City V State
Tenant/Lessee Name
Email
s
Lw, 1. tt
Master Permit No.
11
�' F" Phone #
Job Address (where the work is being done)
Phone #
r¼U 1)2_ 103 N1 3N e3g
City Miami Shores Village County Miami -Dade
FOLIO / PARCEL #
�( 3Z0S • 030 oV(-0
Is Building Historically Designated YES
Contractor's Compan N
Contra tors Address
City
Qualifier Name
State Certificate or Registration No.
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: ❑Addition
Desc ibe or
,.- it
E -mail
Certificate of Competency No.
Phone #
teration
Square / Linear Footage Of Work:
['New ❑ Repair/Replace ❑ Demolition
********* *,* * * * * * ** ** * ** * * * * * * * * * ** * * * ** Fees************* * * * * * * * ** * ** * * * * * * * ** * * * * * * * * **
Submittal Fee $ Permit Fee $ /1®0r 014'
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
Mort
Mortgage nder's Address
Lender's Name (if apph•.ble)
City
State Zip
Application is here:, made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to ' - ' su. I ce 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 willbe done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAIL, 'a TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT, 1� A JR PAYING TWICE FOR
IMPROVEMENTS TO YOUR YRQ ERA IF YOU INTEND TO OBTAIN
FINANCING CONSULT TIT' I LE
� NDER OR AN ATTORNEY BEFORE
RECORDING YOUR .NOTICE 4 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 clbsence of such posted notice, the
inspection will not be approved and a re- inspection fee will be charged.
Signa
Signature
The fo going
day of
Owner or Agent
stru20ent by c owledgede r`
)1)1I
who is pe sonally known to me or who has produced
NOT UB' IC:
ontractor
The foregoing in ° . ment was acknowledged before me this 6
who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC -STATE OF FLORIDA
,` " "140 Monica Agudelo -Florez
Commission #DD987856
ExpiPes• MAY 03, 2014
BONDED TERI! ATL,NTIC BONDING CO.,INC.
My Commission Expires:
APPROVED BY
&go:
My Commission Expires ° ° " .16', Blau ! ?1
JITLY 2011
************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner Zoning
Engineer Clerk checked
(Revised 07 /10 /07)(Revised 06/10/2009)