PL-10-375S Miami Shores Village figMET1731111
Building Department MAR 0 9 2010 gel
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949 -
Permit No. TL
Master Permit No.
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: PLUMBING
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Owner's Name (Fee Simple Titleholder) J cY m IP✓1� Phone # -q61 4 '7-) V'4
Owner's Address L L 1
City \ , 24tate
Tenant/Lessee Name
Email C) C.inD`' C Q i1 � co cd, i
Job Address (where the work is being done)
City Miami Shores Village
FOLIO / PARCEL #
-1NW L![V
County Miami -Dade
Zip alL„,e
Is Building Historically Designated YES NO
Contractor's Company Name
Contractor's Address
Nu NA
Phone #
Flood Zone
City State
Qualifier Name
Zip
Phone #
State Certificate or Registration No. Certificate of Competency No.
Contact Phone
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: ❑Addition ❑Alteration ❑New El Repair/Replace ['Demolition
Describe Work: - i fl 3+ t 4 I Spy- S f\ 99 QY iCV_L -
Square / Linear Footage Of Work:
:s:
***,***** * * * * * * ** * ** * ** * * * * ** * * * ** * * * * ** Fees* * * * *,* * * * ** * * * * * * * * * * * ** * * * * * ** x * * * * * * * * * * **
Submittal Fee $
Permit Fee $ /5-6 ' 2 /* . CCF $
Notary $ Training/Education Fee $ O'OV
CO /CC $
Technology Fee $ 0 -K)
Scanning $ ?j' O0 Radon $ DPBR $ Bond $
Double Fee $
Structural Review. $
Violation date:
Total Fee Now Due $ 104'(9)0
See Reverse side -+
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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 S and AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT:: I �z1 he ire � , ; ation is accurate and that all work will be done in compliance with all
applicable laws
"WARNI 0 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 b±proved and a reinspection fee will be charged.
Owner or Agent
The foregoing instrument was acknowledged before me this cAqie
day of YVV362..0 , 20 lb, by
e or who has prod
As identification and who did take an oath.
NOTARY PUBLIC:
Contractor
ent was acknowledged before me this
,20,by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:'
Sign:
Print:
My Commission Expires:
* * * * * * * * * * * * * * * * * * * * * * * * * **
APPROVED BY
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ry
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Sign:
Print:
My Commission Expires:
Plans Examiner Zoning
Engineer Clerk checked
(Revised 07 /10 /07)(Revised 06/10/2009)