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PL-11-2162[tslo 13(y.,c9 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING OWNER: Name (Fee Simple Titleholder): )f' �! Phone #: Address: T 5 10 V ci g-t2D- City: in t%.1 State: �^ MMOMWEI ig NOV 2 1 2E1 gji By: Permit No. VII o 21 (02' tertpe it No -d ol©Y — 2-'`y Zip: --3" l -3 T/ Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: 715- 1� �o� el a GJ J City: Miami Shores County: Folio/Parcel #: t t — 72 41)Ca 01.5 ' 5-53 Is the Building Historically Designated: Yes Miami Dade Zip: 3 7 , 3(7 NO v Flood Zone: CONTRACTOR: Company Name: S 0 +ke f r <for 1' ■ L G�VY4.4,1* a r S. Phone #: Address: I S '7 1 5" $ • 'iX1 G 14 i c4•*u Gay , ej v : )-t y02 City: i-M I ea ,�..ti, - State: I C L zip. 3 31 5-7 G n- To e..a t) /7,...q- L. tT ' 7 las5 -146 •�26G Qualifier Name: Phone#: 'S's' 5-14)S "! 7.6 b State Certification or Registration #: 5 A c9 o 2-11( 24 Certificate of Competency #: Contact Phone #: $L 23t.-. a S3ai Email Address: DESIGNER: Architect/Engineer: 4 1 p Phone #: Value of Work for this Permit: $ 6 S ° of Work: Address DAlteration Nov Degcripti ffliArk: elL➢itt • "b1i 2! ?J yam* 4, -, arby� Pt i aS, g R� ?i� ?6S31i6�a ace e 10\ Rye l e■c..e ,".-i4 * ********** ** * *** ****** *+x+r+x**>i *** *>k**** Fees***: x*x: ** ******> is* ******** * *********>i: **s:•x**>i ** Submittal Fee $ Permit Fee $ 3 0 CCF $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 33 Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City t Zip Application is hereby made to obtain a permit to i�-ist6d ' indicated. I certify that no work or installation has commenced prior to the issuance of a permit: and that al to to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must bt ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITTS RS, 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_a l a reinspection fee will be charged. Signature A'! �7 \"`�° eg ignatur Owner or Agent The forego' nstrument was acknowledged before me this l4, The fore day of �� ,20_,by N lL' , day of who is personally known to me or who has produced ° +`Q r 1- who is personally known to me or who has produced As identification' I" 1' 4,take'a o th.l 1 ` 7 as identification and who did take an oath. ■ LIC: NOTARY PUBLIC: Sign: Print: `. \1 31;,.c��\ao;.;. �rtt�lllli i9itlkyA My Commission Expires: Sign: Print: My Commission ***************************** c***********` i:*********************************** **** *************************** APPROVED BY �W"" Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)