EL-13-972 (2)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: Electrical
JOB ADDRESS:
FBC 20
a (U
:j �
s
Permit No. =
Master Permit No.
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple
Address: � R.
NO t�/ Flood Zone:
IN.
City: State:' Zip: 22 Q
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:O�1-
Cd Phone#: _5� �S� —S_Y�VJ
Address: q62-61 4,/t",/ V_g !�g
City: ecu <2moi1 (
,Qualifier Name•
State Certification or Registration #:
Contact Phone# Email Address:
Zip: 3A, �S /
Certificate of Competency
DESIGNER: Architect/Engineer. Phone#:
Value of Work for this Permit: $ < Square/Linear Footage of Work:
Type of Work: OAddress OAlteration
Description of Work: ::rE t&t/12
ONew ORepair/Replace ODemolition
Submittal Fee $ Permit Fee $ /® e- i el0 CCF
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CO/CC $
DBPR $ Bond
Technology Fee $
TOTAL FEE NOW DUE $ 1o
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 T6 RECORD A' NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PoROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE,Qa 'O T E11 NT"f M
Notice to Applicant. Asa condition to the issuance of a building permit with an estimated vafiM a ce461ng $2500,.the applicant must
promise in goad�fa�i.4 -that a copy of the notice of commencement dod'construction lien law brocltuurc 41k7fie deliverA;o 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.
Signature`-- '
The foreg in
day o
who fi s perso
-
NO ARY PIU
Sign:
Print:
My Commission
Owner or
meEy
aT--Felged or�
20
gowe or wh� produced
As identification and who did take an oath.
�ptlda I
�a 2p1'a
01�,�v ExP" # EE 1Z.6°' A
C�� c ssn•
bouded tn�ou9t N
Signature
Contractor
The foreg g instrument was a
day of 20 U-,
known to me or who has
r
�uu �i iLr,
before l�e this (�
o
APPROVED BY �,� /� �/�i Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/1=009)(Revised 3/15/09)