PW-16-2027• Miami Shores Village
I
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC
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
JP3C1. T\TED
JUL 19 2016
lR yj
FBC 201`1
Master Permit No:RA.31(V—
Sub Permit No.
❑ EXTENSION ❑RENEWAL
❑ ROOFING ❑ REVISION
PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: 465 Grand Concourse
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County:
Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type:
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
Phone#: 954-453-0806
City: FT. LAUDERDALEState: FL Zip: 33309
954-453-0806
Qualifier Name: JESUS VEGA
Phone#:
State Certification or Registration #: E1608 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:City: State: Zip:
Value of Work for this Permit: $ 1000 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑■ New ❑ Repair/Replace ❑ 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 $ S - Permit Fee $ /57, CCF $ 0 . C3o CO/CC $ 0
Scanning Fee $ Radon Fee $ O. �� DBPR $ d , a S Notary $ 0
Technology Fee $ 0 ` L90 Training/Education Fee $ 0 'Zd Double Fee $ p
Structural Reviews $ 0 Bond $ f ( v 7
I
TOTAL FEE NOW DUE $ (• I 0
(Revised02/24/2014)
•
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
OWNER or AGENT
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument , as ac
day of , 20 , by / 2 day of/
who is personally known to FScIS VFF94-5
nowledged before me this
by
oersonaily know to
me or who has produced as me or who has • ro • uced
identification and who did take an oath. identificatio and who d'd .k a o
NOTARY PUBLIC:
Sign:
Print:
Seal:
NOTARY P
Sig
Print:
Seal:
IC:
as
4
HUBERT NUNEZ
. Notary Public - State of Florida
« "' » = My Comm. Expires Sep 11, 2017
Commission # FF 043679
Bonded Throu'h National Notary Assn
,-
ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss
APPROVED BY
(Revised02/24/2014)
Plans Examiner Zoning
Structural Review
Clerk