PL-12-15021
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
PERMIT APPLICATION
AUG 0 7 2512
FBC 2U jc n�
Permit No. QI 10C-4 "Uri'
Master Permit No. f -C/ Vi;
Permit Type: PLUMBING
JOB ADDRESS: 6C4 14. t) • Jo 7 STREET-
City: Miami Shores County: 11 11 zip: 531 GA
F o l i o / P a r c e l # : 11— 213(p - 0 br1 , 0 0 S 0
Is the Building Historically
OWNER: Name (Fee Simple Titleholder): P'd RD N • ZE 14\E t i D Phone#:
Address: , 4 t4.1.0 . ID r7 S7(2.EE t
City: PtiA% -ti Stun-2.2-5
State: �-
Zip: 33 (o e
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: CAPITA 6E14024 R-A CDN TRACTORS Phone#: aoS -82 T I —(P 2 11
Address: 4 qO (.i) . R yf*4 G r , SATE ES 1040
City: A-4% 614h
Qualifier Name: CA(L(0S A •
State Certification or Re
Contact Phone#: 306 —
DESIGNER: Arclu'
State: Ft-
1142e14-3
Email Address:
Zip: 3301 V
Phone#: 315- 13. -!®
Certificate of Competency #:
cApirA15.-K 1co„rrTZAcrlWs. Coif
Phone#: - 30s°g 9" Z— Wvlor�
Value of,W rk for this Permit: $ el, .640, S
Square/Linear Footage of Work: � � �
Type ofWork: ❑Address iteration C9New ❑Repair/Replace ❑Demolition
Description of Work: MA51 l2- rz...r)f4-4 4 4l M it y get*
******* * * * * * * * * * * * * * * * *** * * * * * * * * * * * ** *Fee ************* * * * * * * * * * *** * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ 31-2- • 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 FT.RCTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDTTIONERS, 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 Ls 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
Owner or Agent
The foregoing instrument was acknowledged before me this __
day of 'Ski , 20 , by Ped(.o 4 . icJEME D ,
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign: / ��
Print: tJ *`1����
My Commission Expires
,9..A • - a a ...
OLGA L. CRUZ
`�. Nota Public - State of Florida
• My Comm. Expires Sep 23, 2013
ZfZ
.,q�/OF
1 : • :.
nded Through National Notary Assn.
* * * * * * * * * * * *** * *** * **
APPROVED BY
/
Signature
Contractor
The foregoing instrument was acknowledged before me this 24714
day of Ti3 t / , 2012.. by CArt.1oS f. • U
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
L.
4,226A
lJ
My Commission Expi,
1
OLGA L. CRUZ
Notary Public - State of Florida
• My Comm. Expires -Sep 23, 2013
Commission # DD 894805
onded Through National Notary Assn.
11, _ - - 4
r -
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Plans Examiner
Structural Review
(Revised3 /12/2012)(Revised 07110 /07)(Revised 06/10/2009)(Revised 3/15/09)
Zoning
Clerk