EL-11-1677Miami Shores Village
Building Department
10050 N.E.2ind 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: Electrical
OWNER: Name (Fee Simple Titleholder):
Permit No.t\ LI 1(T 1
Master Permit No.
CkLZA
6." c. kca, v Pone#:
Address: Gres d Can Got+►r -SQ
City: Ak iaw' 1 cS110 LS State: Ffor +dc\
Zip: .33 t st
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS:
City:
Folio/Parcel #:
Miami Shores County:
Is the Building Historically Designated: Yes
CONTRACTOR: Company Name:
Address: � 2P
City: Lei
Qualifier Name: Phone#:�/� '—'57/1
State Certificatio r Regsion' d2// Certificate of Competency #:
n Y'
Contact Phone# � °" Sf/ % Email Address: G lJ 6% /a. '.
Miami Dade
Zip:
NO Flood Zone:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ /61, ` e Square/Lmear Footage of Work:
Type of Work: DAddress OAlteration ew URepair/Replace ODemolitioonn'
Description of Work: ( ,') , &aii_ / r (i)6i.f l ). ddie
****** i**** �x�x�a ****** *4!�x*** *�xx��x+xx� *x�x:� *** Fees**** * * *4*a: *u ** ** *4 4 4 i:** * * * **** * * * **
Submittal Fee $ Permit Fee $ / i, ,C2 ' ea CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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, BEATERS, TANKS and AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing informatign-is- accurate and' that all work will be done in compliance with all
applicable laws regulating construction and zoni
"WARNING TO OWNER: Y(TJR 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 and a reinspection fee will be cJmjg d.
Owner or Agent
The foregoing instrument was acknowledged before me this ' The foregoi ledged before me thi/
cto
day of ,tbC,. iC20 ., by wa... G c I , day of
who is personally known to me or who has produce who i s
dr i i.... C' leevi92 As identification and Oho ddid tape an oath. ,
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
onally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commi
AITATZ
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th
i3 -2 Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
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ALBA H. AGL'LA
Notary Public - St ;,e of Florida
,9 ,r My Comm. Expires. Jul 26, 2015
'' %°F`,,,, Commiss n '' EE 1 OR Mit-
Zoning
Clerk