PL-13-1982Miami Shores Village
Building Department
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: PLUMBING
RECD x/ ?- ._
AUG 30,_0
FBC 20 4-D
Permit No. ? L 1 4"3 — 1 - Q ` �rD.,
Master Permit NO.jRC" P3 °i /W
JOB ADDRESS: 13(! c'D I v 6 10-3 ST
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): n4 06-ri A. P AA xo Phone#: � 'd " 2,9
Address: t 3(c)® P E 103 Sr
City: M e Ajk( $ C409451 State: F-f- Zip:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: \ JM61 0� !!3 GW.JtC4- it'_" Phone#: - 730Y
Address: _ _� ff q 2- 1v U-) Sr—
City:
Qualifier Name:
- LZCGC_A
.S_ Cp v Z M
State Certification or Registration #: 4'-"C f ! F' 2� S Certificate of Competency #:
Contact Phone #: 3%"- IT' O " '730"-F Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ 0. Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New
Description of Work: fL IOCAT6 kJAS W R. Ca
❑Demolition
Submittal Fee $ t Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
Technology Fee $
TOTAL FEE NOW DUE $ log-
Bonding company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
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 oc en (7) days after the building permit is issued In the absence of such posted notice, the
inspection will not bg approved.Ad a reinspection fee will be charged
,/ Owner or Agent
The foregoing instrument was acknowledged before me this 94
day of , 20 0 , by "IZA5r I Ara J 6V
w rsonally known , or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission
'L— JOSE E1RIZ
MY Comm. Expires Nov 27, 2013
CommisSIon # 00 912225
Signature
11'r 0 Contractor
The foregoing instrument was acknowledged before me this
day of A .201'-1 by ���•+�tal.-
who is �ywn or who has p roduced_ ation and who did take an oath.
APPROVED BY _� -1 °-) 13 Plans Examiner
Structural Review
(Revised 3 /12/2012)Mevised 07 /10/07)(RevisW OG/10/2009)(Revised 3/15/09)
NOTARY
Sign:
Print: •-
My Co . • AR�IAANDO PALENZUELA
�pMMISSION S EE194194
EXPIRES May 04.2016
Zoning
Clerk
�� . f ; j �. if 1 • b
b
l}. FEE IA regSlatio>� as Shores Village ood . a= a aPrevea hqn the
costs of u�_ my nem�Tts mist �m,�o� ,tor�d� 'I`he costs of any ,� ven�enn�sl�m thep�ast12ymonths and the
costs of y pposed imros fie shown on the Thb cost •of v idiust
un15% ..,e�ents ,
include demolition, raw and fimshima�erials (include those donated), labor (inchuiing voluatee aad self-
constrdctibil° 3y o> and management, and ojtrheati add profit'A list' of. items 66 ''costs of
petfoi�ited),' sil�sr'',
which are to be inchuied air ie,exaluded is attached for your reference. (A Copy: bf the'CdIitract
must be attached)
PROPERTY.OWNER:
PERMIT.#
d
�(o tr= l 3 .5 � c A•�°'! a SYt '3! p ia =
ADDRESS: y ,
FLOOD ZONE: -
BASE FLOOD EI:�VATION: °~ 'FREEBOARD: EAST OF FL.CCCi,:
COST OF PAST IMPROVEMENTS (12 MONTHS):
COST OF PROPOSED IMPROVEMENTS:
(ATTACH•COPY OT;CONTRACT)
TOTAL CUMULATIVE COST 0 II "OVEMENTS (past and proposed):
e
VALUE OF PRINCIPAL STRUCTHM (atta 1): _- S'3 ^�
OWNERS SIGMA
PLAN
SIGNATURE: DATE:
DATE: Z�
REVIEWER
PSG PLUMBING SERVICE, INC
3892 NW 125 ST.
MIAMI, FLORIDA
CFC1426257
PHONE: 305 - 796 -7304
Proposal
To: CHRISTIAN BLANCO Date: August 29, 2013
Address: 1360 NE 103 ST. Phone: 754- 214 -2875
MIAMI SHORES, FL. 33138
Project Name:
We propose to furnish all material and perform all labor necessary to complete the following:
Relocate washer plumbing connections
We propose to furnish material and labor, complete in accordance with above specifications, for the
sum of. Four hundred and fifty 00 /00
Payments to be made as follows:
Contractor's signature:
Acceptance of proposal - The
hereby accepted. You are au
outlined above.
Owner's signature:
Dollars $ 450.00
down 50% upon completion
Date: � Z 1 Ll-
price, specificqVions and _conditions are satisfactory and are
I,to do thew6rk ecified. Payment will be made as
Date: 31Z 9 ��
CERTIFICATE OF LIABILITY
INSURANCE 11/21/13
PROMMM Px00hw= kwunom Asomy
3801 SW 107 Avenue
lMoN, FL 33166
Phone (3ti9mso-� (at)22ti�7
THIS CERTIFICATE IS ISSUED AS A MATIPER OF IIt oRMA'i'"
ONLY AND CONFM NO ROM LWON THE CEiUTMTE
HOLOM TW MWICATE ia= ROY AMEND, EXTEND OR
TER TIE COVERAGE AF,Ft D sYTHE
.Ip UMM AIfORDING COV9RAGE. NAIC
wtm PSG Pwrd)hv Service, Mc.
3892 NW 125 Stnee4
01133k0 w, FL 33054 -.
NsuRm A: SooitadwQ Insuforive Conpany
41297
> Bi 1 @Auto insurzirm rhos
11738
11398
R C: Mwarrteo Inuraom CWroany
COVERAM - r�iSURER k _
iNY POUCIE8 CF ff. TOANCE 1 HAVE SEEN
TO THE NNStftD NAMED ABOVE i63iTFLE Po=P1M0i�9 TM_ NO WMiSTANDiie�,
ANY RERTAK f,6df, �, m OFANY CONTRACTOR MM DENT wnw itBSPPCT T4 T>�S CEfZi1F7CATE MAY BE;^+SL1> =D 0>±
MAY fE8. AQt. THE TE tM= Ai�FORDSD BYTIN= FQ[3t S DESCRIBED HEREIN tS SMEOTTO ALL THE TEFU% 80111 ION& AND BONmWNS OFSLiCrI
. ANTE t�+it'C3 8H tttlW WAY HAVE RON RM! ron my aem, iv RYM
C INERAL L4ASAr[Y E
LMM
t � CRC1At Q�AL ilAH1IlTY
f
EACH OCCURRl L
f}
08214QQ C
!wS om 3
0
t j 0
PV=NAL&AWKUW
GENIUMAGGFEUTE 3.000.1
- A('�RECVITtL TAPPt�ss P
Pl Tg -tAi4t OPAC:G %00011
S1
AWONCOU :BAR TY j
j O
!Q ANYAMO -001 0
07109 /f3 07MW14 ,
OpA s 41it�f
AM AUTOS
,e f
$ ® SC Ot1EEDAUTOS 8
80DLY"RY
HMAU=
i Q NON OWNWAUTM 8
8001I.Y 1N.MRY
f �]/ trOC P $'600.00 DW (
(P� aa�dmrt)
` W! $500.00 Ded P
PROPERTYDAMAOE i
rAA�Si�1TY �
i
ppt�lY1RAAN- r
AUT0ftLY- EAACCEAW
OTHER THAN -
{{ A
AUTOOI&Y; AGO
# f7 o=W j] Cis WA 0
, E
EAo" d�E
,q �
AGGREGATE 6.�tt.oc�0;
EJ � t I
I
SCI RE MYM S
vxxwim AM
WCP10020910301c 1
11h8/13 11/18df4 Q
Q w sTA ®o •�
AMIPR0FF 1 0R /PARTNERIEMCUTNE
0FRMJF C"R0CiWDW? N P
P-L EAM ACCMENT ' 1k}Ly�V/V�a►WN
1f w% ddft Hndw E
EL D - FA YM 1,(Q_
s