PL-12-415tc
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• 30 762 4949
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BUILDING Permit No. ji_-44s
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder):2).K0 d , 1 )(J hg V E�e Phone#: _3�_"'
Address: 43 ooy'0 E !9y_'r
City: /�M c_j��_ State: lec o Zip:l
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: xfr '
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Q/ 22 &®%,-2_®
Is the Building Historically Designated: Yes NO �! Flood Zone:
CONTRACTOR: Company Name: ?ft)MR� A)r, /V�CJ� !
• Phone#: 30 2&—" /�
Address: C= 3o T61-1
City: 0&yW_ Q 2b State:�� , Zip: 3_30_'?'0
Qualifier Name: Phone#: 9-5 1'- 293 "-
State Certification or Registration #: 66—e 71029v9) Certificate of competency #:
Contact Phone#: 3QS'' 90 Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ / 0, ® 0 Square/Linear Footage of Work:
Type of Work: DAddress DAlteration XNew DRepair/Replace DDemolition
Description of Work: 1 (Jl�l 3) /2A 1,0
Submittal Fee $ Permit Fee $
Scanning Fee $
CCF $ CO/CC $
Radon Fee $ fi DBPR $ Bond $
Notary $ Training/Education
Double Fee $ Structural Review $
Technology Fee $
TOTAL FEE NOW DUE $ r
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 ititltallation 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 nd a re'nspection fee will be charged.
Signature CNkkO Signatuire L
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Owner or Agent Contractor
The foregoing instrument was a ow ged b re The foregoing instrument was acknowledged before me his
day of _��JlrY �'► `, 20 by day of /'r%Qe�C`i , 20, byis�
who is personally known to mo or who has
NOTARY
As identification and who
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Print:
My Commission Expires:
ho is personally known to me or who has produced
R ds as identification and who did take an oath.
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My Commission Expires � i puma em
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EXPIRES: &m22,2015
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APPROVED BY Plans Examiner
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Zoning
Structural Review Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Date:
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit #: y /�
Date:
Plumbing Critique Sheet
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Review Completed by: Rafael Hernandez
Chief Plumbing Inspector