PL-13-2607Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fag: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
Nov 18 1013
FBC 20
Permit No. P 1 b 3 — � �
Master Permit No .f,C. 13 0? 6 0 �J
JOB ADDRESS: 116 [U C- I y 6
City: Miami Shores County: Miami Dade Zip: ?V f
Folio/Parcel #: \\ Z ! � 00`� — db 6 d
Is the Building Historically Designated: Yes
MESH 1 1 1 rm r'*
OWNER: Name (Fee Simple Titleholder): t '�A $"'�14%Yl ,(1 I��I�1 I )) 1 'I Phone #:
Address: 17-
City: t4 `C k"-N State: 1' Zip: 3\�y
TenandUssee Name: Phone# (30S 1 7 Li — 6 Z6'1
Email:
CONTRACTOR: Company Name: p ao I V Phone#: `� �4 Z
Address: ) ® V' -el. it �'ep ► f
City: Q Yr State.
Qualifier Name: r .0 �Pj Phonek
State Certification or Registration #: l , F-C 14 2D 21 L+ TO Certificate of competency #:
29) Contact Phone #6 � 17,S a 6 4`6 2 Email Address:
DESIGNER: Architect/Engineer: Phonek
Value of Work for this Permit: $�'t 6 / qq Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Submittal Fee $ CU Permit Fee $ CCF $ CO /CC $
Scanning Fee $
Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee i
Double Fee $ Structural Review $
TOTAL FEE NO
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
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. --17 — -. I
Signature .�� � Signatu>�I ��
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 49 G°r , 20 JJ, by C0V 4 W 1 iJ i5 16 day of 40 C15 , 20 j ' , by AhW& C4t JT0
W.
who is personally known to me or who has produced who i rsonally kno o me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: A LfM NL
My Commission Exp'
APPROVED BY
ALE JOSEPH PAVLINex
MY COMMISSION # EESS9471
EXPIRES December 19 2018
�111 -/r -/1-7
Plans Examiner
Structural Review
(Revised3 /12/2012)(Revised (Y7 /10 /07)(Revised 06110/2009)(Revised 3/15/09)
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: %1
My Commi , ",,• • esALEXANpER JOSEPH PAVLINEK
•E MY COMMISSION # EES59471
••, 4, EXPIRES December 19 2016
Zoning
Clerk