PL-13-2650 ` Miami Shores Village
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Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 N0V 2 2, =
Tel:(305)795.2204 Fag:(305)756.8972
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INSPECTION'S PHONE NUMBER:(305)762.4949
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l FBC 20
BUILDING Permit No.
PERMIT APPLICATION Master Permit No R/
Permit Type: PLUMBING
JOB ADDRESS: A3 s i tg j case '
City: Miami Shores County: Miami Dade Zip: " `ccs—
Folio/Parcel#: (YI S 1-% !F=e_ & A ?le- -m ipa s< 92, 3 19 CL
Is the Building Historically Designated:Yes NO ./ Flood Zone:
OWNER:Name(Fee Simple Titleholder): Vic » qi a a Phone#:
Address: , iL1,= �4_�I --
city: OA aw l State: zip:
Tenant/Lessee Name: a Phone#:
Email:
CONTRACTOR:Company Name: hone#:954-G�'1- f89
Address: -1(-Sa N Lu LA �ex
City: f AArQA_,'T-CS - Zip: 33fg 6
Qualifier Name: L A S Phone#:
State Certification or Registration#: Certificate of Competency#:
Contact Phone#: Email Address: L A a esgs a 01 A6®- v1%
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ 2=22, Square/Linear Footage of Work:
Type of Work: OAddress OAlteration EXIew QRepair/Replace ODemolition
DescriptionofWork: 4A1 k1; An 232&A 'Bol 4k4e_- F'TAAJdoec -t
Submittal Fee$ Permit Fee$ 2 ._.- CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$,,,�
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i
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip 1
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
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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 oved td a reinspectionfee will be charged.
Signature Signatur
er or Agent Contractor S
The fore oing instrn as acknowledged before me this JZ The foregoing instrument was acknowledged before me this I
day of ,20,3,by �CJ� day of NC ,2P ,by LL)I S AQ.AtM 1!?,ry 2--
who is ersonall kn to me or who has produced who is personally known to me or who has produced —t C)
As identification and who did take an oath. as identification and who did take an oath.
NOT UB NOTARY PUBLIC:
Sign:
Print: o�Ay Pp# Notary Public State of Florida
Print: — 1
My Com ssi a My Commission E043995 M Commission Expires
v Expires 12/0512014 y p
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)