ELC14-2883Miami Shores Village
Building Department
U 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
Permit Type: Electrical
FBC 20
Permit No.
Master Permit No.Z�/ 1 / — c2U g3
JOB ADDRESS: , � /y/s
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO 11� Flood Zone:
OWNER: Name (Fee Simple Titleholder): S IX0 S1A ®'o-- / /'W.0 Phone #: aO-5' 7.5- OS'd5'
Address: Ao�/=- 1,06" s°V
City: State: go� OX 1AV-4
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: I CftO.0 $e 451O M /C- I AIC- Phone #: ;7" AnCX:)
Address: ?® sue'
City: z2&"0m / State: AL Zip: 3 / 5��
Qualifier Name: Phone #: _505-
State Certification or Registration #: 00 C2 f / <2 9' Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer-
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work:
Submittal Fee
Scanning Fee $
Permit Fee $ A CCF
If
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ �
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
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.
Signaturea"' `' l Si
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this �- The foregoing instrument was `acknowledged before me this 2-
day of �t , 20 , by FA �r Pair® day of all , 20 7 , by
who is personally known to me or who has produced who is personall known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
EXPIRES: May 11, 2014
Bon W TIT Notary Pulft Undenariters
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
` 0 979M I My Commission Ex r!4J:',*W MY C OMMISSION # DD 979267
U14 EXPIRES• May 11 2014
r . ^•far ?r. nun S• 4. ^.dsnvriters i�Q.q` Bonded flrro Notary Public Umierwtfters
fi h'
APPROVED BY ,� Plans Examiner Zoning
Structural Review Clerk
(Revised 3 /12/2012XRevised 07/10/07 )(Revised 06 /10/2009 )(Revised 3/15/09)
e.