PL-07-1961Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33 (38
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATIO
FBC 2004
Permit Type: Plumbing
91'1/ gee/
Owner's Name (Fee Simple Titleholder) A ea GC�®f eer // #Q Phone # 95 -9 7 g4
Owner's Address /19-g12 NE /044 <y-
City /17/Afri,./ G/ c State Fe.
Permit No. PL 7° . /141
Master Permit No.
Tenant/Lessee Name
E -MAIL:
Job Address (where the work is being done)
City Miami Shores Village
FOLIO / PARCEL # /!"— 223e7 -...
Zip 33 1-'3 s
Phone #
Is Building Historically Designated YES
Contractor's Company Name
Contractor's Address 1
City ) I ;.41 m 1 State
Qualifier Name `----2:1 Ih't 4x41
State Certificate or Registration No. G P."6 / %2 4
E-MAIL:
Architect/Engineer's Name (if applicable) Phone #
hone # 3� '6 5 f •- �� f
zip
Phone # g..5 1 4--7
Certificate of Competency No. r
Value of Work For this Permit $dej -AMC) Square / Linear Footage Of Work:
of Work: ['Addition ['Alteration ONew ( Repair /Replace ❑ Demolition
Describe Work:
*******,** * *** * * *,* ** * * * * * * * * * ** ***** * * ** Fees*******,******** ,** * ****** * ** * * ** *,* * * * ** * *****
Submittal Fee $
Permit Fee $ /151. CCF $ (. ZO
Notary $ Training /Education Fee $ 0.40
Bond $
Structural Review. $
Radon $
DPBR $
Technology Fee $
Zo
Double Fee $
Total Fee Now Due $
1 SEP 1,0 2007
�K t®b% t o(. p(l4r ovay .
MIAMI SHORES VILLAGE
CO /CC
vaS tho.'
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: [ 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 building o' fa .i g 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 ee will be charged
Signature ANC
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of , 20 , by day of 20 b
who is personally known to me or who has produced y
p who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires: My Commission Expires:
***************** 1Yl' P1Y' **YY* ***{C1CftlflFtY %1C*1F1:****,k ***% tY' iFi% t' CIICfL' 1FfY1ftY*lI' tYff% ***-* **1C1t1L' 1FtY'% IYtCltltlYlY*'} 1L ']Y'K1F1L'1Y1ti1Y1F1Y***** *fY]Yi * **
NOTARY PUBLIC:
Sign:
Print:
APPLICATION APPROVED BY:
(Revised 02/08 /06)
Plans Examiner
Engineer
Zoning