RC-13-2387Y
BUILDING
PERMIT APPLICATION
Miami Shores Village AK4 A 1V1qe0L--z-'
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 OCT 0 i 2014
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
Master Permit No. KC_ I o _% ` 033 -7 -
Sub Permit No. 1 1-4 —2-19 0
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING [:]MECHANICAL [—]PUBUC WORKS ❑ CHANGE OF [-]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 490 NE 101 STREET
City: Miami Shores County Miami Dade Zip
Folio/Parcel#:11-3206-017-0430 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood tone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ROBERT J BOURNE Phone#:
Address: 490 NE 101 STREET
Cfty: MIAMI State: FLZip: 33138
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: BLUE GAS PROPANE
Address: 1234 NW 79 STREET
City: MIAMI State: FL' Zip: 33147
Qualifier Name: CECILIA MARTINEZ Phone#: 305-900-9609
State Certification or Registration #: 15520 Certificate of Competency M
DESIGNER: Architect/Engineer: Phone#:
Address: -City: State: Zip:
Value of Work for this Permit:t 1-478.44 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration M New ❑ Repair/Re lace
p ❑Demolition
Description of Work: install a 200# tank run 10' of piping and connect range
Specify color of color thru tile:,
Submittal Fee $ Permit Fee $ Y/ 5d ;;; CCF $ CO/CC $
Scanning Fee $ Radon Fee $
DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
IRevised02/24/2014)
r
�U1, 2) ri C�'
Regarding: 490 NE 101 Street
Miami Shores, FL 33147
Anna,
I need to cancel the permit that is currently at Miami Shares Building Department. Customer canceled
contact and is asking for refund.
Thanks,
Cec a Martinez
General Manager
Blue Gas Propane
1234 NW 79 Street:
Miami, FL 33147
LPG 1SS20 r�
ANA ALVAREZ
06-AMISSM # EE122615
PIRES Augmt 16, 2045
l0- 1+14
1:234 NW 791h Street • Miami, FL 33147 • Phone (305) 693-9022 + Fax (305) 693-7511:
www.bluegaspropane.net
I
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. 1 understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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 $250, 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 absme of such posted notice, the
inspection will not be approved and a reinspection fee wll!ke charged. '
il
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day ofi. ���( 20 I by
L! 1 who is personally known to
me or who has produced �) rtye fs kiemas
Identification and who did take an oath.
CONTRACTOR
V90ing instrument was acknowledged before me this
day of 20 1J . by
r..e u 1, A &,- "At z . who iiiersonall i kno to
me or who has produced as
Identification and who did take an oath.
NOTARY PU NOTARY PUBLIC
Sign: Sign:
Print: Kewim.1! N Pltuoy ,,(c Print: LA11 o f" -FO A V,
Seal: Seal:
RLAZARO ARIEL FON"Mo
�IARYPI,ABENI;IA :•�,,ar orb.••
;. MY COINAMM i FF 130M r • `n Notary Pdit - SUb d FtOfld!
a S: June e, ZO18 ^' , MYComm. hill ttN JW/1 13.2018
Apr
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)