PLC-11-1242 (4)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
BUILDING - F R 1 R t y (S (0 /t/
FBC 20
SEP 0 6 2011
Permit No. PLC. —1— it, I tit Z
Master Permit No. t U —5 ci• 6
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): jo1E^1 11 verc —y Phone#: 30S — 305t2
Address: 11 2 ) 00 N L' Z" Ave-
City:
M : atin■ S tI ov 55 State:
Tenant/Lessee Name: & yr/ (�hiyoe�; t-y !
Email: j0 e of va Dr 49 Q ma r I (�� ,f/ o e 0i 11
JOB ADDRESS: 1 t 300 1"(% 174 A ve
City:
Folio/Parcel #:
Miami Shores
(11.13 (900nod
County:
F L
Zip: 3 7 ) 1 b
Phone#: 3/6 -9qq - 0567
Miami Dade Zip: 3 3/ (o
Is the Building Historically Designated: Yes
CONTRACTOR: Company Name:
Address: L .2) '%c( rjti i -,itis
City: 5v101 r I S�
Qualifier Name: 0414 T
R(&- ltry,Ay
State:
State Certification or Reap =!
Contact Phone #: 't� � >`� 0
DESIGNER:
Value o
Type of
NO
Flood Zone:
f t,L' 8i,v(,-
Phone #: ai 514 — Z.3-o000
FL
Email Address:
zip: 3332e
Phone#: q SW - 344 3 — 55 c7 4P
Certificate of Competency #: L F G Oil S r CC 2-
��wl'� r 5H1 wtifple,0101vy. / 644
C_a�•�o�
pA5114., l 160,41,4 ('®.vet tw Phone#: 61 -75 6 - OTIS0
Permit: $ _t: a Square/Linear Footage of Work:
UAlteration Rzviso N New ❑Repair/Replace
Address
Description of Work:
ODemolition
* * * * * * * * *** ****** ** ****** **+x*******x * ** Fees** ***** *** ** **** xw+s******* * ** *x,****** *** *** *
Submittal Fee $
Scanning Fee $
Notary $
Double Fee $
Permit Fee $ 75
Radon Fee $
Training/Education Fee $
Structural Review $
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $�
1%4 42.Scii
•
Bonding Company's Name (if applicable)
Bonding Company's Addis
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 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. s the absence of such posted notice, the
inspection will not be approve 0 I a reinspection fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this
day of (s„,T , 20 // , by D
who is personally known to me or who has produced_
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expire
* * * * * * * * * * * * * * * * * **
APPROVED BY
Signature
Contractor
The foreg ing instrument was ackno edged before e thi l)—
day of ;r id 1720 by / I`t- ,
who is personally known to me or who has produced
0aY9.piB0® •608BBC ®fl OaBOBCBBOY..l.0.00 \1
as iderif cat>� ®.cE oath
NOTARY PUBLIC $� Y aG tee. Comm# DD0798596
.._ Expires 9/9/2012
Print:
My Conunission Expires:
801. FlOtida • ryAssn., inc
4
CWAIM
************************* ********* * * * * *** ** **** * * ** *****
Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)