EL-14-1104Miami Shores Village
Lrd�, Building Department 1M CP
90050 N.E.2nd Avenue, Miami Shores, Florida 33138 MAY 2 9 2 14
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BY:
FBC 20 �O
BUILDING
PERMIT APPLICATION
Permit Type: Electrical
Permit No. Fi"L ILA 0.-1
Master Permit Nol�c1 J 0�q_
JOB ADDRESS: '?t r _N_ �_ _77_5�
City: Miami Shores County: Miami Dade Zip: I
Folio/Parcel#: I I° 3-z'0( - D l �pC�
Is the Building Historically Designated: Yes
NO r Flood Zone:
M
OWNER: Name (Fee Simple Titleholder):r V'« ei�I'i� Phone#:
Address: S .M1 q I S T_
City: State:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: �rN i l� rL_(=--C_Mk 0_ Phone#: rr5 � C �'6-�
( 6
Address: % --C', 25Lj zo'Tt;rzA—
City:._
Qualifier Name:
State Certification or Registration #: EC 13 2 0 6119 Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $ too ` Square/Linear Footage of Work:
Type of Work: ❑Address DAlteration ONew ORepair/Replace ODemolition
11
Description of Work: t,®cv VKX_tV71 X (-- A-5 P ACL_ tss S et
r -y Pt+O/v 15-
���x�x�xx��x��x��x���x�ea�x�xx��x���x��x�x�x�x�x�xx��xx��x�u�x�x��xFees�x��xu���x�x�x�x�x���x�a���x���x�x�x����x�m���x�x��x��xm��x�x�����x
Submittal Fee $ Permit Fee $ l dO d / CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ r /C
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
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 sten (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reagpection feg. will be charged
Signature Signature &
Owner or Agent
The foregoing instrument was acknowledged before me this
dayofd�aLA ,20L,by U0iie Al
who is personal3'y known tome or who has produced�Lj=W-.
ov1 t2 As identification and who did take an oath.
NOTAR 7LIC:,
My Commission Expires:
REBECA M.PASTRANA
MY COMMISSION A EE872624
EXPIRES: Fobnwy 07, 2017
Contractor 17
The foregoing instrument was acknowledged before me this L
day of Ma , 20 �, by ail 566 ,
who is pers ally known to me or who has produced*
ga&-T=1:—P . as identification and who did take an oath.
APPROVED BY 743'A -/,y Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
NOTARY
Print: U
My Commission Expire •XPIREBECA M. PASTRANA
MY COMMISSION S BUM24
% ERES: F&mvy 07, 2017
Zoning
Clerk