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PLC-12-2065Miami 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 FBC 20 Permit Type: PLUMBING "/b f✓L t? SEP 132012 Permit No. !' 2- (2a6 Master Permit NoCCI 1 F_ !aiD OWNER: Name (Fee Simple Titleholder): 1)e l VL-J �� -� Phone# 3�S � — �' r Address: 1 I:, 4<k {/��(� li •5`r�� Q.W City: W .Q W . 17. State: F L. Zap: 33 /t Tenant/Lessee Name: Phone#: Email: V,bQ.I64. 10 JOB ADDRESS: q %) PG City: Miami Shores County: Miami Dade Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: Zip: 33 In CONTRACTOR: Company Name: &llyQJ.r �t EE4 PI gAtt- 1(1111 , L.(.C., Phone#: 401-7V -g7,1 Address: S v Ai . S+ e. Pct 4R tt , S (L4e 1+4,5- City: A.1 +O. VMA:J L+ C.. i ■ w. 4 State: F i, I∎ Qualifier Name: l` 1 Oe v— 4 K t il e a cL State Certification or Registration #: C C. i i. v1 CP 7s 1 Certificate of Competency #: zip: 39.704 Phone#: t/O 7 -- 9cf - ?e Contact Phone#: DESIG c i Q D Email A d d r e s s : Q k 5 g I% C, k lM efoLA C C. +, v ngin C K A. w ji l.e. t t Phone#: 3'S 9:5V o93.67 ee- a. a ✓ Square/Linear Footage of Work: ?I b .? S F Alteration ONew OReoair/Replace ODemolition Value of Work for this Type of Work: Description of v +fry i�.11�Cai Su f i -. ee $ 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 $ 1.%1` 40 Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) . n 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 i barged Signature Signature Owner or Agent The fo oingi- nstrument was acknowledged before me this 1? The foregoing instrument was acknowledged before me this day of« -tee' t , 20 G�, by t l I ti LI )� , day of c a 2O a by ©C c lb _It - pi P t who is personally known to me or who has produced t s) who is personally known to me or who has produced As identification at0011130k an oath.vu'"► -- as identification and who did take an oa t.11 P176;;, % 1tI6/20/6 . Contractor NOTARY PUBLIC: Sign: Print: } u', ° i• n/ssi °n ;' My Commission Expires: c'• Cf ij3p ?9'Q. \� ,,, tOFiFLO o NOTARY PUBLIC: Sign: Print: My Co `ticah�l C My Commission EEO 516 Expires 10/15/2014 * * * * * * ** * * *o * * * *** *** * * * * *** *** ********************************************* * * * *** * * * * *** * * * *** * * *** *** * * ** APPROVED BY � � - N' /2 Examiner Zoning Structural Review Clerk (Revised 07n0/07)(Revised 06/IO12009XRevised 3/15/09)