EL-13-1608 (2) I
Miami Shores Village
Buil.ding Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 J�L 1 2/0 93
Tel: (305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
FBC 20
BUMI)ING Permit No.
PERMIT APPLICATION Master Permit No.
Permit Type: Electrical
JOB ADDRESS: C-x L)C-7 C4 ax
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): FftiMO,.+ei 90f Phone#: 3_5'
Address:��/�J
City: &4v-�e�s State:
Tenantlessee Name: Phone#:
Email: (row- e-arl
CONTRACTOR:Company Name: LL `'z hone#:�19__Y COS
Address: _ A4) <
City: Stater Zip: J3 3 S
Qualifier Name: 4ec+or A-rzolo, Phone#:tm-11(d 05+
State Certification or Registration#: C 501 Certificate of Competency#:
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: Phone#:
C�
Value of Work for this Permit:$ & + Square/Linear Footage of Work:
Type of Work: OAddress DAlteration ONew ORepair/Replace ODemolition
Description of Work:
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 t t 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 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 charged.
Si tore Signature
fl Contractor
The foregoing instrument was acknowledged before me this 1 The foregoing instrument was acknowleliged before me this
day of 20 a by�-%A C{ S (��Q ;day of by
who is perso y known o me or who has produced o is rsonally own to me who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOT LIC: NOTARY PUBLIC:
Sign: Sign: 1 '' -
Print: 1 Print: Pk 1 &C a
uclic My Commission Expires: Elieser Placeres nda My Commission p ry PA varez 196011
MY Commmlon EE
pt ` Expires 03!1712017 884860 4a MY C�°m6120 6
�XQ1065 Q
Mir c
4t9FsY4t�t4t4t4t�'c4:$4e4e9t4c�oY&9toY�'tk9e4e9n1t9t8e4r9e9teYie�Y4e�Y*9ek4e4z9t�1e9esfro1roY4etk9t9t�Y4:4n@aYnYkxYvkdnk�ek�Y9e&ode&�tk�Y�Yak9tArtk ie4ilYde9roYde9etk3nk4t9t4:�Y4:Y9:da9t�9roY
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012XRevised 07/10/07XRevised 06/10/2009XRevised 3/15/09)
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