EL-13-2198Miami 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
FBC 20
Permit No. F1�`qj
Master Permit No.
JOB ADDRESS: _ _ � Al' , r/
City: Miami Shores County: Miami Dade Zip: .��/ �•Y
Folio/Parcel#: /l - _?2-0_'S"_— 01,7 -
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder):/ ��� i �� y Phone#:
Address:
City: /1- r aver State: P Zip: 371 ?,C--
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
F0 /[cv 1-4C •/ J
YO -2 ?W_ 1'G//
Address: S<,d 421- C% C&, fie- /G/
City: State: Zip:
Qualifier Name: &ea Phone#:
State Certification or Registration #: ,7Certificate of Competency #:
Contact Phone#:� �.�✓ — �� Email Address:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $ f� ,S'C/U Square/Linear Footage of Work:
Type of Work: ❑Address
Description of Work:
DAlteration ONew ORepair/Replace ODemolition
Submittal Fee $ L < UU Permit Fee $ /0,0 "400 CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
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 , u'Vit with an estimated value exceeding $2500, the applicant must
promise in goodfaith that a copy of the notice o construction lien law brochure will be delivered to the person
whose property is subject to attachment. A _ y of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven er the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reins pe }�` fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this �C
day of 20 /-?, by /%
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:—
Print: xz.
Signature
Contractor
The foregoing instrument was acknowledged before me this ,
day of 20 by G /--
�Zt�
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign: <
Print: ` ?1 /-1. • °o
My Commission Expires:
: °; ANTONIO My Commission
MY COMMISSION #FF05280
EXPIRES September 10. 2017
�� i3
APPROVED BY L.�� s?�' i0� Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
ANTONIO SAY
MY COMMISSION #FF052893
EXPIRES September 10.2017
Zoning
Clerk