EL-13-1039 (3)IM
` . J 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
M��1 13 2013
By.
FBC 20
Permit No.
Master Permit No. 1 01-1
JOB ADDRESS: zo D wo ni OW
City: Mia i Shovom✓ ®r�es p unty Miami Dade Zip:
Folio/Parcel#• C 0 1 Q.
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder):614116TA1-.!;7 ' Phone#: '" " fTi
Address:/� Q C
City: 1401 State: 4 Zip: �%J✓ ✓
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 7y� ����� ��^ �/� Phone#:
Address:
City: ff
State: c
Qualifier Name: CZ® A) Phone#:
State Certification or Registration #: g 2,®8 Certificate of Competency #: _
Contact Phone#: Email Address: M
DESIGNER: Architect/Engineer: Phone#:
Zip:
4SC �-3 -6oW.
Value of Work for this Permit: $ 6a?"® E' SquarenUnear Footage of Work:
Type of Work: ❑Address �I DAlteration ONew ORepair/Replace
Description of Work: .�V �—
"A,
Submittal Fee $ Permit Fee $ 1-4� G U CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
ODemolition
r
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
zip
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
B1PROVEMENTS 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 properly 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 approve and a reinspection fee will be charged.
Signature � Signature
&U� w�
Owner or Agent Contractor
The foregoing instrument was acknowledged foe me(s The foregoing instrument was acknowledged before me this,
cl—
day of , 20 �, by day of , 20 S , by QA10n B.QY�k ,
wtio is uersonally known o me or ho has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
My Commission Expires:*
n'V'ril 22, 2914
EXPIRES: Ap
tes
Bonded1g 11114 Semi
�
NOTARY PUBLIC:
Sign:
Print d in i w 44 � 1
+; �? WCOWSSION # EE 867174
My Commission Expires: EXPIRES: January 22, 2017
BMW Thru Notary Pi Underwriters
APPROVED BY y/� /� %Y�'y Plans Examiner zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)