PL-13-187Miami 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
1-3 -1.-Jn
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
JOB ADDRESS: �W;4!�) A& 377
Permit No.
Master Permit No.PU
City: Miami Shores County: Miami Dade
Folio/Parcel#: %/ 3eZ6 /Vq 53,0 r
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple
NO IL/ Flood Zone:
I
Tenant/Lessee Name: Phone#:
Finail:
CON
Addri
City:
Quali
State
Cont-,
DES]
Valtu
Type of Work: ❑Address
Description of Work:
Submittal Fee
❑Alteration
Permit Fee $ /0 0'
CCF
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
JORepair/Replace A ODemolition
CO/CC $
DBPR $ Bond $
Technology Fee $
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 b 'lding permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of c encement and construction lien law brochure will be delivered to the person
whose property is su ect attachment. Also certified copy of the recorded notice of commencement must be posted at the job site
for the first inspe ion w 'ch�rs sev (7) days after the building permit is issued Int Bence of such posted notice, the
inspection will t be app v a d ;, einspection fee will be charged.
Signature
wner or Agent
The forego'g ins ent was ackn wledged before me this
day o , 20 a, by ,
who is erso y known to me or who has produced`
As identification and who did take an oath.
NOTARY PUBLIC: // v%ate^ I nii�n— Xf.
e•�
My Commission Expires:
Signature,
The foregoinument was
day of .2
who is personAy known
NOT.
Sign:
Print:
My Commission
owledged before me this
�c, J r- A3#Zn!&1& ,
or who has produced.
who did take an oath.
1•� Jo014, 2piy
APPROVED BY Plans Examiner Zoning
Structural Review
• a
R
(Revis l3/12/2012)($evised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Clerk