EL-13-707Miami 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: (3057 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: Electrical
FBC 20
APR 02 1
a
SYeooava000000000__o___
Permit No. tj
Master Permit No. YC
JOB ADDRESS: 6`7 I CU I i Z
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder):_ Da -1), L__ Phone#: q 05 5710 LIL L-
Addressss: X33 C, ������!, Z � r
City: State: Zip: 33
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: A t -c- p P zi5-_- ` � Phone#:
Address: 1/ 0, 9 1 &tv / _S*
City: T&A L U - e:;2 0 ® &2L) State:
Qualifier Name: PEZV, ® C z_- Phone#:
State
P'ti % . I Z Certificate of Co t : -j: r I
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Value of Work if this Permit:
Type of Work: ration
Description of W611P 2'� a.� v4r:rw
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Submittal Fee $ Permit Fee $ ZZ:r;dP'0 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 approve{ and a reinspection fee will be charged. n
Signature C10/60 Signature
Owner or Ag en or
The foregoing instrument was acknowledgore me this The fore instrument was ac ledged before me this
day of C1 , 20/2 by , 4ZO c --
day of G� %(s , 2p , �L t� L -
who is personally known to me o u •ed __ who is perso 0
v
As identi b ho didi oa onuWAV t take. ath.
r►E►D� CERZPubNts otpo ws
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NOTARY P IC: a°uFacile • AIN
State of NOTAR
F`OP:o,: MY Comm. t:xpires Oct 3. 201 a 1 IIRp t:cnnm. 251
016
Commis # EE 84025016 F Rl
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Print: C� T1U Print:
r° Notary Pubic - State of Fir^
My Co t My Co glary Pubis - State of F otic
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ea My Comm. Expires Oct S f : , . Canm. kms Oct 3.20!
o? °' Commission # EE 81az _ Commison * EE 841251
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 3/ 12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
BylFEB 2—tin -
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