PL-13-2080Miami 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
FBC 20
Permit No. V 1) 3— 2EK)
Master Permit No. -OL– j3 – V;5 – 1
JOB ADDRESS:�LfflW11-F Q _011`
OEM -
city. Miami Shores County. Miami Dade Zip: '33Y38
Folio/Parcel#:
Is the Building Historle4y Designated: Yes NO Flood Zone: X
OWNER: Name (Fee Simple Titleholder): _ 61P J�eA \ &"ia j '&Loyp5, r -L Phone# 3 VA Z 9 ?L[ (`�
Address: 5_4 AX IM 11 -
City: H c O64,V,, g y� res State: L Zip: -a�4zx
TenanVLessee Name: Phone#: �—
Email: eAaALo cc
CONTRACTOR: Coany Name: Phone
Address: \%-O , ,Ockt -4 -zo 0 �
City. L IState:
Qualifier Name: \)QAk " S (X� Phones
State Certification or Registration #: C 1� to �Z Certifica o Co cy #•
Contact Phone#• � 61 � 1 Z
Email Address: ��n <
DESIGNER: Architect/Engineer: Phol
Zip: _
V16 2 -Irl VO -L-)
Value of Work for this Permit: $_ 02.,®(X) . Square/Linear Footage of Work:
Type of Work: OAddress ZIAlteration ONew ORepair/Replace ODemolition
Description of Work; c -L 1 c o c'�
'c �0<cti car )lVu 1aS
&de�frtah4aY.YaYabt aTeaYdr�iraakstr�Ydrdrdear�Ydnaxtdh4�YaY�Ter�e�rk�YF�aYt,Y9a�r�Y�Te&�e�rr�edr�tadr�r,kir�k�Y�,k�Y.r,kiF,4,YiraY�la�r+4+�WaatrsY,x�r�Y,&ik
Submittal Fee $ Permit Fee $ L 2 5CCF $ CO/CC $
Scanning Fee $ Radon Fee $
DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Doable Fee $ Structural Review $
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 attachmeyt. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which oca4f seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be aBProP9VP6 a reinspection fee will be charged. a n
or Agent - # -
The f go' instrument wasWwleed beforethis,(
day o 2X5 by
wh oft
tom or who has produced
identification and who did take an oath.
My Commission Expires:
The fooing ent was acknowleAged bef=me20
day of 20 �3,by V�Q
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign
Print:
APPROVED BY Z� __12.—fj Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012)(Revised 07/10/07)(RvAsed 06/10/2009)(Revised 3/15/09)