PW-16-20281
•
i
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
❑ PLUMBING ❑ MECHANICAL 0 PUBLIC WORKS
JOB ADDRESS: 1095 NE 95th Street
FBC 200ii
Master Permit NolW ILp AoA-15
Sub Permit No.
❑ REVISION
❑ CHANGE OF
CONTRACTOR
❑ EXTENSION ❑RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores County:
Folio/Parcel#:
Occupancy Type: Load: Construction Type:
Miami Dade Zip:
Is the Building Historically Designated: Yes NO X
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): RIGHT OF WAY Phone#:
Address:
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: TECO PEOPLES GAS
Address: 5101 NW 21 AVE. STE. 460
City: FT. LAUDERDALE
Qualifier Name: JESUS VEGA
State: FL
CAK
Phone#: 954-453-0806
Phone#:
Zip: 33309
954-453-0806
State Certification or Registration #: E1608 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 1000
Type of Work: ❑ Addition ❑ Alteration
Square/Linear Footage of Work:
❑■ New ❑ Repair/Replace n Demolition
Description of Work: INSTALL A NEW 3/4" PLASTIC GAS SERVICE LINE LINE BY DIRECTIONAL DRILLING
Specify color of color thru tile:
Submittal Fee $ '61 Permit Fee $ J • CO/CC $
Scanning Fee $ 3 Radon Fee $o� Notary $ 9
Technology Fee $ o 0 i1 Training/Education Fee $ 6 2Q Double Fee $ 0
Structural Reviews $
(Revised02/24/2014)
C CCF $ O. 60
a•`� DBPR$ 'cPC
Bond $
TOTAL FEE NOW DUE$ J09-. 16
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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 a reinspection fee will be charged.
Signature Signature v4. -l.])
OWNER or AGENT
CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument w1as acknowledged before me this
day of , 20 , by (Z day of
who is personally known to
ryr s Yt g 4 S , who is
me or who has produced as me or who h
rsonally know
as
identification and who did take an oath. identificat'•n an• who did take an oath.
NOTARY PUBLIC: NOTARY
Sign:
Print:
Seal:
APPROVED BY �'(,,� 14/!
(Revised02/24/2014)
Seal:
Plans Examiner
so.zPpY ....
HUBERT NUNEZ
C�i
Notary Public - State of Florida
My Comm. Expires Sep 11, 2017
Commission # FF 043679
Structural Review
Zoning
Clerk