EL-12-2182 (2)BUILDING
PERMIT APPLICATION Master Permit No.
FBC 2003
Permit Type: Electrical
OWNER: Name
ame (Fee Simple Titleholder): U r
Phone#: 7 <g "/ /
1 /
Address: q ?6 / i +) & l
City: 1 I' aim „Gorhs State: _/-
Zip: 93/ c
Tenant/Lessee Name: /l.) f , Phone#:
Email:
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
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�l NOV 1 6 2012 J.iii
Permit No. I IA—a,1&9
JOB ADDRESS: /1)
City: Miami Shores
County: Miami Dade
Zip: %a
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company Name: i) )C&SL1 /EL_ )%C /1)6 Phone #: 30, 75F""Z6�(')
Address: (c'-4 /viz) (26 S7-
City: / / 11 //dim / State: i'
Qualifier Name: ',To h /) cl 4'/1(.d / /�
State Certification or Registration #: E G () /1 1 �% Certificate of Competency #:
s
Contact Phone#: ")K- /CS' -2_006 Email Address:
DESIGNER: Architect/Engineer: Phone #:
Phone#:
Value of Work for this Permit: I I �® �V u
$ Square/Linear Footage of Work:
Type of Work: Address OAlteration
Description of Work: _ 6-
ODemolition
7r:
'm' �)
„l1
et 07. 7r. i ?lam ;'tA�5, (V
****** ** ************* *** ******* ** * *** * *Feeege** * **** *** *+ x****+x+x****+x***** ** * *** ****** **
Submittal Fee $ Permit Fee $ jOr4'e
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ o
Bonding Company's Name (if applicable)
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
VAN
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 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 reinspection fee will be charged.
Signature
Signature
Owner or . gent Contractor
The foregoing instrument was acknowledged before me this /VP( The foregoing )instrument was acknowledged before me this 7
day of l'/d U , 20 j 2, by e�De &N.:J/4 , , day of MOO , 20 12', by '-;ie'/)I7 Is ' III
who is personally known to me or who has produced 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 P BLIC: NOTARY PUIHLIC:
Sign: Sign: Mattf !% '
Print: (r �'lY • � Print:
My C. ion Ex fires: -f! ' 1-. My Commission Ex
***************** ** 41*** **** +x****** *** ********+x*+x+ + x*+ x*********** ******* *+ x******** *+ x+x ****** ***+x*********
/t / p' Plans Examiner Zoning
APPROVED BY
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)