PL-14-460A15\111 131 -
BUILDING
PERMIT APPLICATION
FBC 20
Miami Shores Village
g
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
Permit No.
Master Permit No.P/ /e/ (5'0
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): 1—'h; Per- f e(4l, Phone#: 30S- 53 2--(a39 (o
Address: i (t S N E
City: Vin i Q rv\ i State: Zip: 3113 S'
Tenant/Lessee Name:
Email: P"a✓ig t pawl ; M &M ai q w� (. co�{j�
,
J VVr
JOB ADDRESS: 3c.4 N tA) Q 1 L 5+- .
Phone#:
City: Miami Shores
Folio/Parcel#:
Is the Building Historically Designated: Yes
County:
Miami Dade
Zip: 33 ► S1D
NO )C Flood Zone:
CONTRACTOR: Company Name: rqr A KfriOki,? S hone#:
Address: ICI 43)\ NO a
City: ilk ( k 1 State: Zip: 33 I k
Qualifier Name: K 1,,,k & �'t'CL c Phone#:
State Certification or Registration #: SK-. ()D 6k 6 Certificate of Competency #:
Contact Phone#: Email Address:
30s1)5( AS -9
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ 13
Square/Linear Footage of Work:
3p0 L
Type of Work: ❑Address ❑Alteration 141I4ew lepair/Replace ❑Demolition
[.
Description of Work: j _ , , [� � • � I
-
**********:**********:*******************Fees****************************************: ***
Submittal Fee $ Permit Fee $ 4 300L— CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE 73'. g(. fiSDO
•
604.
Bonding Company's Name (if applicable)
B nding 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 foregoing information is accurate and that all work will be done in compliance with all
applicablelaws 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 commen- 4t must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In e abse , ce of such posted notice, the
inspection will not be approved and a reinspection fee will be charged,
r 7.
Signature
ge-&('`-'451-1
Owner or A nt
The foregoing instrument was acknowledged before me this .27 .27
day of -a �2201 , by-�,nrtfer 11Yh
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign: f
Print: K b1e
My Commission Expir
******************
APPROVED BY
""""'; KEMBLE ETTRICK
e Notary Public - State of Florida
•i My Comm Expires Sep 19, 2017
,F-��� o Commission # FF 055732
•
Signature
Contractor
The foregoing instrument was acknowledged before me this a7
• day of i' NiMO 20 5', by e" alek
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sigh: i
Print: 45
My Conimissi
�• i
********************
(ti Plans Examiner
Structural Review
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Notary Public State of Florida
Sheryl A Mendes
My Commission EE017513
Expires 1012312014
Zoning
Clerk