PW-16-3425v
BUILDING
PERMIT APPLICATION
El BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION
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
Master Permit No.
Sub Permit No.
❑ EXTENSION RENEWAL
El PLUMBING ❑ MECHANICAL •PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
970/
JOB ADDRESS:
RECEIVED
DE21.2016
BY'
Pw
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s
FBC 201
eW i -ib-34-ZS
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County: Miami Dade
Zip:
Folio/Parcel#:
Occupancy Type: Load:
OWNER: Name (Fee Simple Titlehold
Address:
Is the Building Historically Designated: Yes
Constrbciion Type: Flood Zone:
NO X
BFE: FFE:
: RIGHT OF,WAY% Phone#:
a,� }.
City: State:,
Tenant/Lessee Name:
Email:
Phone#:
Zip:
CONTRACTOR: Company Name: TECO PEOPLES GAS
Address: 5101 NW 21 AVE. STE. 460
City: FT. LAUDERDALE State: FL Zip: 33309
Phone#: 954453-0806
Phone#: 954-453-0806
Qualifier Name: JESUS VEGA
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: PERMIT RE -NEW FOR A GAS SERVICE LINE
-to pcplett..t PIN u--16 -154o
Specify color of color thru tile:
Submittal Fee $ 5 +A+ (] Permit Fee $ /CV
Scanning Fee $�'1 • 60 Radon Fee $ c c-5
Technology Fee $ 0 ' Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ CD • 60
DBPR $ • 0-5
O' 20
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 11 • I Vi
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 VS ..,. U - Q.
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of , 20 , by _ j2� day of , 20 6 by
who is personally known to 1cs�s V ;P 5 ,
me or who has produced as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
personally known to
as
identificati jT d who did take an oath.
NOTARY , C:
Seal:
****************************** ****sss***********s*******s************s*****s*sss**s****s*s****sss
APPROVED BY )- 16 Plans Examiner
(Revised02/24/2014)
Structural Review
Clerk