PL-13-1747Miami Shores Village
Building Department AUG ®�
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 as
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION"
Permit Type: PLUMBING
1/ I
FBC 20
Permit No. P j t 3_ 1_7 H
Master Permit No.Q. 13 1__ I5
JOB ADDRESS: 5!& /J 1 C is 2.� E
City: Miami Shores County: Miami Dade Zip: X331
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple
Address: J9.G1) M
City: int
Tenant/1,essee Name:
Email: - re o v.
0
State: •i'% Zip: 3 3% 3 e
m
CONTRACTOR: Company Name: rLr�- JL1.4 � 0 Lt,*, r- /•v C_ phone#:(✓0c�) -7 -2 3 k,L(
Address: J ( 3!g /-t i Ln,.j AL,,Z-
City �1 sOAII r 0 State A'� Zip: 33/3
Qualifier Name: fes- PL/4 -./ 0-0 L c.e a f-
State Certification or Registration #: ti/t Ir O ® Z Certificate of Competency #: ®U®& / J9 7
Contact Phone#: 7 2, G fo L Email Address: A-" c -o -Syf C Q a. -TW
DESIGNER: Architect/Engineer. Phone#:
Value of Work for this Permit: $ �qoo Square/Linear Footage of Work: 5:E
Type
Type of Work: OAddress OAlteration ONew .l-ot/Repair/Replace ODemolition
Description of Work: Ye_P (' 111 ��� j I i®!/ � %i r0e)m
r
Submittal Fee $ Permit Fees 2- = CCF $ CO/CC $
Scanning Fee $ Radon Fee $
DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double 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 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 and a reinspection fee will be charged.
Signature .
Owner or Agent
The fore ing instrument was acknowledged before me this
day of, 20 1 3by -�
who is personally known to me or who has produced rtvp
. As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Signature
Contractor
The foregoing instrument was ackn ledged before me this
day of 2J by 6 l tc�7
who is personally known to me or who has produced AA P
as identification anA who did take an oath.
NOTARY P LIC:
Sign:
Print: ``,��ta�--�•• i��b''
My Commission Expires
APPROVED BY O e -46- 13 Plans Examiner
Structural Review
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
..
0\,;. Zoning
Clerk