PL-14-1106Miami Shores Village�-
Building Department��
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ���` 6 Lq
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
JOB ADDRESS: 3 % 04 J.K. 9 Z % 1'
FBC 20dD
Permit No. PL--) _
Master Permit No. F --L-- I '" 1
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder):._A. ft e. -V A wtw t �,
Address: I Q m o ad i /2
City: F *gnet4 State: (... Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: A. U K ^ .
�/ /� C Yom+► � �M►�+�a. Phone#: 7 Zy —&Z—
Address:
Address: Is 7 0�1`or
City: OK / 0-9" I .J f &7 P4, -State: FL Zip: 3 T/ 11 k -
Qualifier Name: bw.. KJ A. %J Phone#: 3tLS 4LAns; P -7 Z
State Certification or Registratio Certificate of Competency'#:
Contact Phone#: Email Address:
DESIGNER: ArchitectJEngmeer: Phone#:
•a
Value of Work for this Permit: $ —0 Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: 4,ft Mftd&& tIL GL a '7-40I A- ('y94.-ItA yrr .�.
�Fees,�*�r,�,��r,x
Submittal Fee $ Pemit Fee $ '�L a CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
r
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 willlotle approved and a reinspection fee will be charged. 7
/ /�trument
or Agent
The foregoiacknowledged before me this .27
day of p%d_, 20 A, by � A sew ` C & &aa &% ,
who is persdYnally known to me or who has produced
—ADv"ao _- -R1036ke an oath.
NOTARY PU .'I R�` MY OOMNgSSION # FF 098874
tea,;
EXPIRES: March 5, 2018
''h Bonded Ther NOWY Puft WMemrd w
Sign:
Print:
My Commission
Signature.
Contractor
The foregoing iiffstrument was acknowledged before me this
day of , 20 /9, by
who is perso y known to me or who hasroduced
ft grAc in &-l` L 011M oath.
THO
NOTARY MY COMMISSION # FF 098674
EXPIRES: March 5, 2018
s ti o?a fit dW Tft ;;iY Pub�b
Sign:
Print:
My Commission
APPROVED BY Plans Examiner Zoning
Structural Review
(Revised3/12/2012)(Revise107/10/07XRevised 06/10/2009)(Revised 3/15/09)
Clerk