EL-09-388 311jn°I �c. p � lz �XC��3�i'M
Miami Shores Village
Building Department. BY:..... ' ..
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972
BUILDING Permit No. t,:::-109 -3751(
PERMIT APPLICATION; Master Permit No. 25 2 a �
FBC 200'1
Permit Type: EL ECTRICAL ��
Owner's Name(Fee Simple Titleholder Phone#�!
Owner's Address
city IXAg1 l t5"'a!9 s to zip -:5r 3/ "ro
Tenant/Lessee Name Phone# e
Email
Job Address(where the work is being done) `��� �/✓ /`'' Vie ®`-t
City Miami Shores Village County Miami-Dade zip
FOLIO/.PARCEL#X13 Z D G 017�� n
Is Building Historically Designated YES NO__>6 Flood Zone
Contractor's Company Name �- �e �.��►• d Phone#3®.0 A S�1 y
Contractor's Address 1 f Z3 3 w 1 tis lb U�,
City4 .®llu%. State � 3 3 Ar 1. p;
Qualifier Name - Phone# 3 0 3 a.J /
State Certificate or Registration No.-E C_u da Z• Certificate of Competency No.
ConWlion,j �� �9 E-mail G (C.C'tw i c .C.o rr-,
Architect/Engineer's Name(if applicable) �fC2 K- G! LPhone# 3oc�,<. ;L O,;
Value of Work For this Permit$ 00, DO
Square/Linear Footage Of Work:
Type of Work: DAddition teration ONew
❑ Repaidgeplace D-Demolitio
Descriork:`
1 '�.
n O�
C
Submittal Fee$ Permit Fee$_ ���'a'® CCF$ - 0 b Co/cc-
Notary$ 15.0D Traainh%WAucation Fee$d Technology Fee$AM
Scanning$ Radon$ DPBR$ Zoning$
Bond$ Code Enforcement$ Double Fee$
Structural Review.$ Total Fee
See Reverse side ->
Bonding Co 's Name(if applicable)
�'fi>ompany'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 hment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first ' e ' n w ' o cu seven ays t*er the building permit is issued In the absence of such posted notice, the
inspection w'ft not b ap r a re' pect' a c
Signa e Sionature
Owner or Agent Contractor
The foregoin ins t was acme this The foregoing instrument was acknowledged before me this
day of ,20 ,by0V day of 4 o*`� ,20 e l by �� t J
who is personally known tome or who has produ who is personally known to me or who has produced
--
I soft cation and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: QSign:
Print: Te Print: �
My Commission Ex ' My
R " Notary Public State 0f Flora o``""•. �� Q\� N
Tens Jervis
MY COMIssim DD740365 �z
pow Ex0e801N512012 '
APPLICATION APPROVED BY Tans Examiner Zoning
Engineer V �"`t erk checked
(Revised 0711 W07)