PL-04-277 Miami Shores Village
Building Department
10050 MEW Ave Florida 33138
Tel: 5) 6.8972
BUILDING 2 110 Permit No. PL •
PERMIT APPLICATION - ------ Master Permit No.
FBC 2001
Permit Type(circle): Building Electrical umbing Mechanical Roofing
Owner's Name(Fee Simple Titleholder) RO-rC_4 � IP 'hone#
Owner's Address 161GW W &r
City1A u of rri A-O tC5 State K, zip u3l�U
Tenant Name Phone#
Job Address(where the work is being done) Jts OIL4-
City Miami Shores Village County Miami Dade Zip Igo
Is Building Historically Designated YES NO V
Contractor's Company Name StWKA� Mir,, Ukiv c �"�c. Phone# 0aAS) (fo(-fo G 3
Contractor's Address PO 50Y a16 S
CitylA,0 I k4 wa a d State r-1 Zip 'S�'St�3
Qualifier
ArchitectlEngineer's Name(if applicable) Phone#
S Value of Work For this Permit Square Footage Of Work:
Type of Work: Addition ❑Altand on []New RepairAkeplace El Demolition
Describe Work:
r, •r,x�a*s��**,�*,r�,r,�s�*,���sr,rCC�rr�rF�,as�etssw,�**�,���,r,��s��r,�+r�*a,�***s�
Submittal Fee S Permit Fee S 01 J'®® CCF S s CD 0
Notary$ J' Tralning/Education Fee$ 2 C) Technology Fee s •3:�-
gcanning S 19K
Radon S Bond$
Code Bdorcement$ Stmoural Plan Review.S
Ck5t
Total Fee Now Due S � �� � ���` �
(Continued on opposite side) =
Bonding Company's Name(if applicable) N
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 CONDMONERS,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.
KWARNING 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 and a reinspection fee will be charged
Signature Signature
Owner or Agent Contractor
The foreggoii"n/�/g��instrument s acknowledged before me this•2L The foregoing instrument was acknowledged before me this 2 3.
day of —f ' br O day of 20(gby
who is personally known n'fi' iLW n "' who is personally kn to me or who has produced
BXPIUS:& �p � Hu
�• l Ct?J^c AS andw , r _ l:olMllssloli 84
NOTARY PUBLIC: NOTARY PUBLI +°; Expires:Jul 13,2007
Bonded
Sign: cam '^ Sign: fit Atlamicling
C
Print Print
My Commission My CommissionExpu
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(Certificate of Competency Holder)
State Certifiicate or Registration No. Certificate of Competency No.
APPLICATION APPROVED BY: ` Plans E---
Engineer
Zoning
Cho 10/14103
Miami Shores villageI m bi n Permit
P u g
10050 NE 2nd Avenue ----- -
Phone: 305-795-2204 Permit Number: PL2004-277 °`
Printed:9/23/2004 Page 1 of 1
Applicant: JACQUECINE JOSEPH
Owner: JOSEPH JACQUECINE
JOB ADDRESS: 55 NW 94 ST
Contractor STATEWIDE SEPTIC CONNECTIONS Contractor's Address: 3590 SOUTH STATE ROAD 7, SUITE 26
Local Phone: 305-661-6633
Parcel# 1131010340120 Legal Description: 153 41 MIAMI SHORES SEC 6A PB 12-54 LOTS 19&20 BLK 167 LOT SIZE
Fees; Description Amount
FEE2004-9534 Building Fee $175.00 Total Fees:$185.17
FEE2004-9535 CCF $0.60 Total Receipts:$185.17
FEE2004-9536 Notary Fee $5.00
FEE2004-9537 Training and Education Fee $0.20
FEE2004-9538 Technology Fee $4.37
Total Fees: $185.17
Permit Status: APPROVED Permit Expiration: 3/21/2005 Construction Value: $400.00
Work: pump&abandon septic tank
Signed: (INSPECTOR)
In consideration of the issuance to me of this permit,I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibil'ity for all work
done by either myself,my agent,servants or employes.
Signed: (Contractor or Builder) BY: