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PLC-08-2136Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING � �X PERMIT APPLICATION ���� FBC 2004 Permit Type: Plumbing Owner's Name (Fee Simple Titlehdlder) Q.4 lL�one (1 8) 321 Z 10 U Owner's Addr ss i 2 0-cL 2 City 0/ u�- —Qu. State `�`-' •1 Permit No.P) Ce S 1) t Master Permit No. Tenant/Lessee Name E- MAIL: I e -3< �... C Job Address (where th -work City Miami rt'1' '� County FOLIO / PARCEL # �� 't6 `,4 �� Is Building Historically Designated YES :f NO zip 01t, 5/ Phone # Miami -Dade Contractor's Company l`' Name /WAS Contractor's Address /� � 44/ !„Z,�$1 Ad City 1�6 i -a,m` . State F1 Qualifier Name Phone # ; L, • zip -22i3 zip 11033/6'5 Phone # State Certificate or Registration No. Certificate of Competency No. E-MAIL: Architect/Engineer's Name (if applicable) SA 09 II ore Value of Work For this Permit $ S �C� Type of Work: Describe Work: ['Addition ❑Alteration [New L. LI ,7) P Repair /Replace ❑ Demolition r/ ********* * * *********** ************ ****** Fees** xxxxx ************* **** *********** . . ****** * Submittal Fee $ Permit Fee $ ./ 7S'" Notary $ Training /Education Fee $ Scanning $ Radon $ Bond $ Code Enforcement $ DPBR $ CCF $ CO /CC Technology Fee $ Zoning $ Double Fee $ Structural Review. $ Total Fee Now Due $ See Reverse side -3 Bonding Company's,Name' 'f applicable) Bonding Company's Address City tate Mortgage Lender's 1' ame (if ap. icable) Mortgage Lender's Address City Zip State Zip Application is hereby made to obtain a permit to do the work arid installai ns as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will Ile performed to meet the standards of all laws regulating construction in this ju isdiction. I underrtand,that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFF[DA IT: [ certify that all the foregoing information is accurate and that all work will be done in com lianc applicable laws regulating construction and zoning, p e with all 1 "WARNING TO OWNER: YOUR FAILURE TO PAYING TWICE FOR IMPROVEMENTS TO CONSULT WITH YOUR LENDER OR COMMENCEMENT." RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, AN ATTORNEY BEFORE , RECORDING YOUR NOTICE OF Notice to Applicant: As a condition to the issuance o a building t f .% g permit wr,n estimated value exceeding Ss2500, the applicant must promise in good faith hat a copy of the notice of commencement and .2r%nstruc4on lien law br5 lure will be delivered :5o the person whose property is subject to attachment. Also, a certified copy of the :--,:corded nolice of commencement must be posted at the job site for the first inspectior4 which occurs seven (7) days after the building permit is issued. In the 'sbsenc • . suc . • sled notice, the inspection will not be approved and a reinspection fee will be charged Signature The foregoing jn da of �` Y 9wner or &gent strumeht was ac nowledged before me this 7( ______ 0p by goo IP /1-em r`i�� (who is personally know;ji to metor who has produced .f1s identification and who did take an oath. C:' NOTARY P Sign: Print:► 4 i My Commission Expire'S: 1 :4?Yi'LTT�?C - ,.TE *w* *xx * *xx**x ,,• ©M FLORIDA vas 17, 2012 ING Co., INC- Signature Contractor The foregoing instrumentwas acknowled ed be ore me this 7 day of g , 206e , by A r CN � who is per Wally known to m or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My. Commission Expires: 4cxsca 4cxx xaY eY �exxxxx *,p3�� ,',�x,*,* * * * ***�4xx RivaS "' : Doris C. ylni ,.; Commission #DD754046 6 %1 Expires: MAR. 17, 2012 Nap TRW Anomie BONDINGC0.,IIr lans Examiner APPLICATION APPROVED BY: (Revised 02/08/06) 177 Engineer Zoning