ELC-12-927 F e� WTICIFILEE
MAY � 2 Lu �
Miami Shores Village
Building Department BYoo__®_______________o
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 No. tiri1 0--9'2:1
PERMIT APPLICATION master Permit No. �2. �.q--
FBC 20
Permit Type: Electrical
OWNER:Name(Fee Simple Titleholder): \I ����� `f'P Phone#: T5 L(-51(-7—3 3_1
Address:
City:_* ( S AOt£f State: FL Zip: 3
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: 6
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated:Yes NO -19:� Flood Zone: yP�/i
CONTRACTOR:Company Name: Phone#:
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration#: Ce ate of Competency#:
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: y,T &c Phone#: —316—_23
Value of Work for this Permit:$ /I Odd Square/Linear Footage of Work:
Type of Work: ❑Address e ❑A eration ❑New Repair/Rep ac ❑Demolition
Desc on of Work:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State 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 n be approved and a reinspection fee will be charged.
Signatur Signature
er 0r Ag t Contractor
The fore 0i instrument was a o before me e foregoing instrument was acknowledged before me this
da of ,201� ,b day of ,20_,b ,
Y I-"' y y
who isersonally known to me or who has prod ced w is personally known tome or who has produced
/– As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: _ . NOTARY PUBLIC:
Sign S Sign:
Print: ClA�dl a.hiic-State of Florida
015 Print:
M Commission Expires: �_•H '. , o Comm•Expires 128810
My p -My Commission#EE Assn. My Commission Expires:
Natio
nal Notary
Bonded t
APPROVED BY �r� ��h��'l —0-1Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)