PL-11-1639F Miami 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: PLUMBING
OWNER: Name (Fee Simple Titleholder): Q -a V,
Permit No. V E lid U 69
Master Permit No.
k V Phone#: _� C_ W 3 ?0 3f
City: A -t --t v State: Zip: 6
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: _67' �j ki 1 I I- g
City: Miami Shores County: _
Foho/Parcel#:
Is the Building Historically Designated: Yes
NO
id Zone:
CONTRAC OR: Company N e. -SO LK-4Lx— Phone#: 2 8 73 G -
Address: l Fit,
City: State: I_ Z` 6 Z_
Qualifier Name: O A- Phone#(/0 7 G�
State Certification or Re ' tration : C-+ C Certificate of Co peten cyy#:
Contact Phone#� b k Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑Addre DAlteration ONew XrR_ air/Rep ce
Description of Work: �a S� " k� C) (�t. � �3' ,L
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $
ODemohtion
k) (2, a. 4
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 WITIf"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 va a ceeding $2500, the applicant must
promise in good faith that a copy, of the _notice of commencement and construction lien law ro ure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of com a ement ust be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In th absen of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
Owner or Agent C ntractor
The foregoing instrument was acknni before me this The foregoing instrument as ackno re me this
day of 20 , b day of 20 LL, by ,
who is personally knownwho has produced ✓' who is personally known to me o produced��
4''�
's tification and who did take an o° as identification and who did take an oath.
NOTARY PUBLIC: s.•• NOTARY PUBLIC:
Sign: `' Si.(iQ
Print: NOTARY PUBLIC•°' :13F1.OFFLORIDA c �'3 �9 Print: `"�u'4• the A
My Commission Exp Cc' 97 b is a t
an ,`DDS 929o� My Commission E rT :10, 2013
,,�iy a ,,•, :� ::�. F, 10, 2013BONDED TII F'.' A*P MC H* ONDI'm C0.,=
BONDEDTHRU'i...:,..:'.:--�I';GCO.,M
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APPROVED BY / Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)