EL-11-1619Miami 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: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: Electrical --
OWNER: Name (Fee Simple Titleholder)-�
City: State:
494 j R -41t
Permit No.j, l (— I (4*A� 5
Master Permit No A/l __ 1 15
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO
Company Name:
Address: / V 6
City: M l i1 i
Qualifier Name:
State Certification or Registration#: � 4 12 0
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Zone:
Phone#:
of Competency #: '
Value of Work for this Permit: $ quare/Linear =lace
ork:
Type of'Work: DAddress DAlteration ONew
Description of Work:
A . 7N % 9�
rP`
Submittal Fee $ o Permit Fee $ �✓��� CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
ODemolition
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 rhe 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 ` Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this 1 The foregoing instrument was acknow ed before me this-1—
day
hisday of ' 20 Imo, by day of 0
who is personally known to me or who has prowho is personaown to me or who has produced A,--
S — b1 7.' 0 As identificati6i *(1
NOTARY PUBLIC:
Sign
Print: — ---
My Commission
APPROVED BY
Fritz Mathunn
eCom nIFEl n#DD997929
JUNE 10, 2013
THRU A. L;C 1!0\D1NG CO„ INC.
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Plans Examiner
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission E
Fritz Mathurin
? Com„ ssirn # DD897929
Expires: JUNE 10, 2013
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Zoning
Structural Review Clerk