EL-13-119 Miami Shores Village
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Building Department .JAN 13}
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 No.
PERMI.T APPLICATION Master Permit No. 12J 2,2L,
FBC 20 tC
Permit Type: Electrical 41an OWNER:Name(Fee Simple Titleholder): a(. ji'c^w Phone#:
Address: Al F /0 a 4-,
City: I i w w. S�a, c s State: 1-'L Zip:
Tenant/Lessee Name: --r- Phone#:
Email: La t, (^(' L
JOB ADDRESS:. I off.o ( U E (0 a S +.
City: Miami Shores County: Miami Dade Zip: 3 3 9
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone: V O
CONTRACTOR:Company Name:_'1_1e_ ed,;2 A1115"a, Phone#:
Address: go
City: State: Zip: 9K7.3
Qualifier Name: Phone#•
State Certification or Registration#: Certificate of Competency#:
Contact Phone#: ."3G S- S Of-SO 0 '/ Email Address: fO &,veo V e.-
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ Square/Linear 7ep7r/Replace f Work: 'J-
Type of Work: OAddress C'i'" teration ONew ODemolition
Description of Work: &Q w ( / 4 r&-L e.. Ct e(2 11 a La
7 n r
Submittal Fee$�� °� Permit Fee$ 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) RJ^ oL ot o
Mortgage Lender's Address & �;_s mow �.�a ✓cQ
City `"L 4 a, % State_ = Zip �-�
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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 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-natice, the
inspection will not b approved and a reinspection fee will be charged.
Signature I '/- Signature �®
Owner or Agent Contractor
The foregoing instrument was ackn wled ed before me this The foregoing instrument was acknowledged before me thi vit�
day of 20- ,by �,�,. l J T , day of 20 J3,by fQ
who is personally known to me or who has produced qEEEonally kno to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:% G S�0 "S-�- ���- °��°� NOTARY PUBLIC:
Sign: Si
Print: Print:
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Wks
My Commission Expires ' lSS{py 4 EE0074 My CommisSi !EE 004742
FdOrEMFIES:fee 28,2014 " . El1F ES:,lone 2b,X114
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Saw tluu6tdow" '"',��a�' AAn�fl�uBt�g�la�etY 6avioes
APPROVED BY Flans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)