PL-12-1805Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
n7 Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20 ID
Permit Type: PLUMBING
RECOVED
SEP fir,
Permit No.P L i 2--LYC:ET>
Master Permit No.
Owner's Name (Fee Simple Titleholder) `�r�/ 1)"4," Phone # Se S- 75-3 - 40 %
Owner's Address 3 3 3 A®&- i 5
City /9%/ /1��" /�/a'S State J.:: e Zip / 3
Tenant/Lessee Name Phone #
Email
Job Address (where the work is being done) 3 -3 -Z/ � , Z s
City Miami Shores Village County Miami -Dade Zip .53/3 d
FOLIO / PARCEL #
Is Building Historically Designated YES NO Flood Zone
Contractor's Company Name Phone # 3®C
Contractor's Address
City/y 014-114"
Qualifier Name SyLL-!yi't�
State Certificate or Registration No.
Contact Phone
J - Zip .3 i /"" %
Phone # 965- V1 d Y 3
of Competency No.
Architect/Engineer's Name (if applicable) ',Phone #
Value of Work For this Permit $ `telco o Do
Type of Work: ❑Addition ❑Alteration
Describe Work: TTU.1'i 00j'� L 1 VA Q 2 -1!P-1
Square / Linear Footage Of Work: _
blew ❑ Repair/Replace
P -ch — l ss"rim to we • %4A law
tz^;17 a
❑ Demolition
Submittal Fee $VY ermit Fee $ CCF $ CO/CC $
Notary $
Scanning $
Double Fee $
Structural Review. $
Training/Education Fee
Radon $
DPBR $
Technology Fee $
Bond $
Violation date:
Total Fee Now Due $ I
See Reverse side -->
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 approved a reinspection fee will be charged.
Signature
caner or Agent Contractor
The foregoing instrument was acknowledged be a this 13 "'' The foregoing instrument was acknowledged before me this-cl;*
day of S -ef l- , 20/5 , by (7oll,- ` , � /?,-d da 0 (a, by 1 1 l >�
who is personally known to me or who hip � ced who is personally known to me or who has produced
As identificatio &w -ho did take an oath. \ /as idZntification and who did
NOTARY PUBLIC:
Sigr
Prin
My
NOT
Sign:
Print:
My Commission ExpMYC0WWIN#EES
EXPIRES: dune ik 2116
APPROVED BY 0-1 / 7— Plans Examiner Zoning
Engineer
(Revised 07/10/07)(Revised 06/10/2009)
Clerk checked