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Miami Shores Village -
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Building Department aPR Ls
90050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY.
Tel:(305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
FBC 20
BUILDING Permit No. z5-_/ IV— 763
PERMIT APPLICATION Master Permit No. �'' 751
Permit Type:Electrical
JOB ADDRESS: lag N D Sizera't
City: Miami Shores County: Miami Dade Zip: 33 (CJS
Folio/Parcel#: 11'ZI 3(o e O(0 " O 131)
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): 00 i U_1FZ.1"1 O At-MADOx Phone#:
Address: 539 NVQ I0 r0-17� ' t'eET
city: "1 A i A+A i �NAQ►Z� State: -F L-9l_i L->A Zip: -33
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: 1DA•W E LOF C-1 t rA t✓ 1 t'� L Phone#:19,&1k3 4q -35 00
Address: -Z0 ZOO tA W 2n 6 jNJJ jerJy C-,- zt� '�G'0
city: f�t 4►.-1'� �?AtZ��t�S Slac Zip: ��q
tate: -rLAl?�
Qualifier Name: '1Z b 1�'_IL pJ-�I�OlL1y �3 L�,(DcM�j Phone#: 4M 94+'
State Certification or Registration#: F-C i S 00 5 A 4'3 Certificate of Competency#:
contact Phone#:*416 O:R 35 0 V Email Address: VCtVJ elect i c, 62 A.7-V ° net
DESIGNER:Architect/Engineer: Phone#:
Type of Work: LiAddress LiAlteration p ONewORepair/Replace ODemolition
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 foreoi information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning. k..A��/Z A*
"WARNING TO OWNER: YOUR F 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 appy ve and a reinspection fee will be charged.
a d
Signature Signa 'TZ'
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument wacknowledged before me this
day of ,20-&,by day of 20 ,by ,
who is personally known to me or w o has produced who is personally known to me or w o has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: r
MY Y Ws January 11,2015 My i 19�cilresSnnG SS #�EE054428
",I��'', Fto4datJotaryService.eom .ESnuary 11,2015
(407)396 0153
(407)-j§841 53 ^:_ :•arviCe.cOm
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APPROVED BY -2 —r 14'A610— Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10rAW)(Revised 3/15/09)