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Miami Shores, FL
Phone: 786.718.0444
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Miami 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
JOB ADDRESSA9 KL V c (� -TK- C�Z-c
DEC 2 0 2 12
FBC 20((----)
Permit No. t2--2LJ
Master Permit No. U - 1 a-2-9 G
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
or
OWNER: Name (Fee Simple Titleholder)' p l Ir�� i�"1L��"� i.C.l ` "►
Address:
City:
State:
Tenant/Lessee Name: Phone#:
Email:
Name-, r " &9 U 1 40AC XV C Phone#: 2J
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $ 0 � `T Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑Newt
❑�Re,pair/Repllace� ❑Demolition
Desciptionof Work: Y4li-7
Submittal Fee 6` Permit Fee $ ��
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ 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.
Owner or Agent
The foregoing instrument was acknowla bef a me Z�,
day of �, 20a.by
wr fsper ly known to me or wl%has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sig
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of ZZCl , 20 11—by
who is personally known to me or who has producedj:�: 1 �
Print:QI
* WC MWION#EEOOM
My Commis ion Expires EXPIRES; August 23, 2014
Q
9>FIon? Baded ThM BW0 Nohgy w=
ge $a +k =k nk yk Lk sIa 9k $e tg �k =k � ik sk ga s$ ak $s sk ak sk d= gs $a =k =k $a a$ zk � i k N � �k sk sk sk ik ak ak els sk sk sk sk sk ak ak � ak nk � Ha Hs �k ek �k ak
APPROVED BY 910 ial ��`� Plans Examiner
Structural Review
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
as identification and
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
It�han oath.
Zoning
Clerk
I
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ON
SEQ# L12080500147
REN LAWSON
SECRETARY
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2012 THROUGH SEPTEMBER 30, 2013
DBA: 28930
SIMPSONS HOME INC Receipt #:PLBi MIBNG/LWN SPRNKL/CONT
Business Name: Business Type: (CERT PLUMBING CONTR)
Owner Name: PAUL A SIMPSON Business Opened:il/04/2009
Business Location: 16 NE 4 ST STE110 State/County/Cert/Reg:CFC1428071
COCONUT CREEK Exemption Code:
Business Phone:
Rooms Seats Employees Machines Professionals
1
For Vending Business Only
Number of Machines: Vending Type:
Tax Amount Transfer Fee NSF Fee
Penalty
Prior Years Collection Cost Total Paid
27.00 3.00 0.00
0.00
0.00 0.00 30.00
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non -regulatory in nature. You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
the .business is sold, business name has changed or you have moved the
business location. This receipt does not indicate that the business is legal or that
it is in compliance with State or local laws and regulations.
Mailing Address:
PAUL A SIMPSON Receipt #03A-11-00006276
16 NE 4 ST STE110
Paid 08/28/2012 30.00
FORT LAUDERDALE, FL 33301
2012 -2013
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ON
SEQ# L12080500147
REN LAWSON
SECRETARY