PL-12-2164 Miami Shores Village
BuildingDepartment ����
p Noy 14 012
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972 y
INSPECTION'S PHONE NUMBER:(305)762.4949 BUILDING Permit No. PLP—
PERMIT
LP PERMIT APPLICATION Master Permit No.V--r,1154
FSC so �O
Permit Type: PLUMBING
OWNER:Name(Fee Simple Titleholder): 4A/WW D /. 10W AXW.M4."Phone#: 7$.-4yV4'2 SO0
Address: o& OP7 �'- jMro .�
City: /�/% % 1/f®iY�f state: 10=Z zip: .F3/3r
Tenant/Lessee Name: A11111 Phone#:
Email: we �f3o�. tom
JOB ADDRESS: it1201'
City: Miami Shores County: Miami Dade zip:
Folio/Parcel#:
Is the Building Historically Designated:Yes "�VO
Flood Zone: y
CONTRACTOR:Company Name: D 1' Phone#:
Address: t/ /-
city: State: zip:
Qualifier Name: Phone#:
State Certification or Registration#: Certificate of Competency#:
Contact Phone#: AgA, --2 Y4- Z fvD Email Address:_ y ,451 A/ ¢,UL. tor»
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ f"oD Square/Linear Footage of Work:_ /o 91f
Type of Work: DAddress OAlteration ONew @iCepair/Replace ODemolition
Description of Work: R e-m VY0- + 4f&40 &&_ee
RexAoyt ♦ Berg I•r/Ibl A isjVosxA.
ee�*e���**F�e�n*a•��eexe�xxm�+s*�*��+�eexa+�ax�eme+x�ex�a��*a��
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 ca
py' f�tlie'recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after- t building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee�{- charged.
. ;
Signature i� Signature
Owner or Agent h Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of �"' ,20�2,by'` 6-d'-Zk Hday of .20_,by ,
who is personally known to me or who has produced t!� �r2 who is personally known to me 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: ='. b Sign.
Print: 'v,: o o= Print:
My Commission Expires: My Commission Expires:
o W
APPROVED BY "�� Z� Plans Examiner Zoning
Structural Review Clerk
qa w
(Revised 07/10/07XReviwd 06/IWN9XReAwd 3/15/09)