PL-10-118011
Miami Shores Village
Building Department
f0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fag: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type: Plumbing
Owner's Name (Fee Simple Titleholder)
Permit No. t- 1_- % - 10 . i 8 0
Master Permit No. P -C c0 .,10 - 11-19
Owner's Address �3-bOM e -M V)(3 L-ONA C -M P �.rS �2 2
City,iGy, iS�`1.. State �.- Zip Jd
Tenant/Lessee #
Job Address (where the work is being done) b:;) -
City Miami Shores Village County
FOLIO / PARCEL # " - 7tJe 0 b - O `.
Is Building Historically Designated YES
it IC96 -Dfo�
Contractor's Company Name 6 PY 4—' an 1,' Pr . Yj� e'—' — Phone # 9!5� 9 72--
Contractor's Address e,
CiState ,6-�Zip
Qualifier Name ��� _s-� �� �F o Phone # 25--5e e' 7 Z
StateCertific to or Registration Nom/ Certificate of Competency No.
O
Architect/Engineer's Name (if applicable) Phone #
AN
Value of Work For this Permit $ 1 D Square / Linear Foo U Work:
T g
Type of Work: ❑Additionn []AlterationWew F1Repair/rReplace El Demolition
Describe Work: Pro k1,dC2 a .w� � v��r�y � Q � �y�.r��i� P . Solo -'y
^t,Fees,�,��,x�,v,��.,�,�a,v,v,�,r,r��,�,�,��,�,x,�,�,�,�,�,vv+��,��*,��uw�a,��ua�r
Submittal Fee $ Permit Fee $ / 50 CCF $ CO/CC
Notary $ Training/Education Fee $ Technology Fee $ _
Scanning $ Radon $ DPBR $ Zoning
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverse side ->
N p
R
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 pew;tt�i mated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and ao o l"r 4 w brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded ~ tice o) ', ommencement 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
�ffOvedandd reinspection fee will be charged.
r
loo
Signature Si4a6-gnature
or Agent n Zor
The foregoing instrument was acknowledged before me this '� The foregoing instrument was acknowledged before me this
day of au. 20 c ® , by �/� I s Oct e go •oD day of JLtv C 20 1 b by CbwAAA /tic '�X4 i a
who is personally known to me or who has produced who is personally known to me or who has produced
NOTARY
Sign:
Print:
My Commission
As identification and who did tame anoath as identification and who did take an oath.
� i 6 rag
t [NARY7BLIC:
RICHARD
EXPIRES: OCT 16, 2012
APPLICATION APPROVED BY:
(Revised 02/08/06)
Sign:
Print:
my
G/4?e/l01,
p(pIRES: OCT 16, 20�
edihruu9h 1s4S1� Insura�e
----------r-r-r-r�r�
Plans Examiner
Engineer
Zoning