EL-13-2578Miami Shores Village
Building Department
10050 N.E2nd Avenne, Miami Shores, Florida 33138
Tel: (305) 7952204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER.: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit iwe: Electrical
NaV 13 20
Y- o -o -o----
FBC 20 1 C)
Permit No.
Master Permit No.
JOB ADDRESS: % N F q
City. M = Shores county: _ Miami ,Dade
Folio/ParceW.
Is the Badding Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple
Address: '::;' q'9 M
city: - cutin l 6 d1= State:
Tenant Name:
Email:
CONTRACTOR:
Company Nam: �� Phones: -3®�—� ��
Address: � ��(� �c � • �� S
city:-
State• Zip: -3 3
QualifierName• /_V15 vie-*rA Phone#: 30 5,--- 31 13.4
State Certification or Registration#: FC l 3— CO4 -7 certificate of Competency
Coy tact Phone#: i 3,V Email Address: /1 �
Vae,of
Work for tbis P�n�' it:uare/Lines;r Footage of W
�l of*-.
Tylaz of Work: G]Address �UAlteratian / pNew ORepairAUT1 ce ODemoliti(m
Description of Work: t- 7. ' Py tv, e__e_
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Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $
DBPR $ Bond $
Notary $ Training/Edneation Fee $ Technology Fee $
Doable Fee $ Straetaral Review $1 n
1i
Bdnding Company's Name (if applicable)
Bonding Company's Address
City
State zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
city State
J
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
constriction 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 constriction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COM IENCEMENT 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 cweeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which'occors seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged. sI
Signaxum
Owner or Agent
The f oing instrument was acknowledged fore me this � The f %oin ent was acknowledged before me ths
i
day of 20, by day of 20,� by (1/
WY is personally known to me or who hasproduced /i who is personally known to me or who bas produced
, "I
As identification and who did take an oa& as identification and who did faire an oath.
NOTARY AC**NOTARY PUB YANELLE ALONSO
YANELLE ALON$O • • MY COMMISSION #�oear2s
MY COMMISSION #FF06=8
aFP EXPIRES October 16.2017 4 as EXPIRES October 16. 2017
Sign: Sign: o e WW . FIO mm
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APPROVED BY plans Examiner Ze►ning
Structural Review Clerk
(Revised 3/12/2012XRev;sed 07/10/07XRevised 06/10/1009XRedsed 3/15/09)
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