PL-14-94 Ly� . Miami Shores Village
`
Building
u ding JAN 2 12014
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax:(305)756.8972 Y`
INSPECTION'S PHONE NUMBER:(305)762.4949
FBC 20
BUILDING Permit No. Q�A
PERMIT APPLICATION Master Permit NO.F�F
Permit Type: PLUMBING
JOB ADDRESS:- 230!Z Ale 7 N IA
City: Miami Shores County: Miami Dade zip: ,3.��✓B
Foho/Parcel#: /i a 2 0 6 00 ;z®O(YD
Is the Building Historically Designated:Yes NO x Flood Zone: /ya
OWNER:Name(Fee Simple Titleholder): rvwf C Phone#: -731b A
Address: 130 / A)e el W /"/-
s
City: 11818 "1_ ,��jb� State: IA- .3e
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company NE 4 4S S E 4 PL UIT,00 6 d o. Phone#: 30 Y-,?Y3` 710
/.1r
Address: ( E 1,30
City: /V /&M0 State: F11 zip:3316
Qualifier Name: 3_0 4 IV M. 14 JLS S L S L( Phone#: ro 7 '
State Certification or Registration#: d 111"10 Certificate of Competency#:
Contact Phone#: , I °8?3'71 YO Email Address: �-/� ����'d���d' //� ✓ ��T
DESIGNER:Architect/Engineer.. Phone#:
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Value of Work for this Permit:$ It 2�e• Square/Linear Footage of Work:
Type of Work: ❑Address ❑Altera ' n ❑New ❑Repair/Replace ❑Demolition
Description of Work:. ..
Submittal Fee Permit Fee$ 100 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(ifs 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,TANKS and AIR CONDITIONERS,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 o a building permit with.an estimated value exceeding$2500, the applicant must
Pp .f g P g' PP
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 charged.
Signature —?'� � - Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this, 20 The foreg ' instrument was acknowledged before me this+26
day of /x,20 t by "/(- `)U)O RF day of �"�`1� ,20/V,by J O H/� IV. W7Z
who is sorally known me or who has produced who is personall y known 9 me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: UI�G� P�wa�,, Sign:
Print: �-S T//� r�" J��/ Print:
My Commission Ex My Co irebONWPORM
tfi( IS I�Ohi� 2t6 '•*_-- W COMMON 8 EE 871216
EXPIRES:May i(Y,2u17 EXPIRES:May 30.2017
`:• bonded O May 30,20erwaiters 9onded Tfrru Notary Pub�o Uruiernrritera
4rYoYk�YY:Y9e4nYY4:4e9eY 4r9c9cYY&4e4rdr4e4nY4eYoY&Y4ca43eFrFr kBrsYsYaYtr4aeY4r
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)