RC-14-934 (2) Miami Shores Village AVG 16 2016
x
Building Department By
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 +[
INSPECTION LINE PHONE NUMBER:(305)762-4949 ��
F BC 201 qC
BUILDING Master Permit No.G
PERMIT APPLICATION Sub Permit NoT
❑BUILDING :�<LECTRIC ❑ ROOFf?JG ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKSHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: l l/FloodZone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): ���� 1�//VG LM j�� Phone#:
Address: /UE !26
City: Ad/41 tl 4 State: ig Zip:
Tenant/Lessee Name: Phone#: C
Email: &(0 c� l/`_/ �i�9�
CONTRACTOR:Company Name: is l E c�Yr C l�//� Phone#:C�) S Z' S� J 7 f
Address: /S�G� S(1 sU (� Q C✓t= 'G
City: A4 �/ State: �C. Zip:
Qualifier Name: a `'`'t ti r/LO 1/ 4 d-/) (3"t L Phone#:
State Certification or Registration#: Wil'. (L r3 'ZC Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
0 /a
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ ��ae CCF$ CO/CC$
Scanning Fee$ 3 - CC) Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 9"210 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 a se ce of such posted notice, the
inspection will not be approved and a reinspection fee wi be charged. f/
ASignature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
f! 5� day of 14P 17f C 20 �c by day of Ile�'f,L 20 /� � by
4 L,�/��/Z who is personallyn to adL't 4 ✓ y[�i/4dAQP2 who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
i --
g ' JORGERZEAU
Sign: ' R Ross Sign: NFFI19045
ON WF119045 *5,,. ' EXPIRES
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Seal: Seal:
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APPROVED BY ��/R16- /6 Plans Examiner Zoning
Structural Review Clerk
(Revised 02/24/2014)
♦SNORES Miami
shores Village
F �
logo Building Department
OR1DP 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N. --/ —/y 7
Z)� ,/ (�
Owner's Name(Fee Simple Title Holder): Phone
Owner's Address: 7
City: MIAMr" State : Zip Code:
Job Address (Of where work is being done): —)4, /v /
City: Miami Shores State:—Florida Zip Code: 33 /-38
Contractor's Co paany Nam' CLf �' Phone#: / ���
Address: ] � N
City: (,k-, l S te:_ L_ Zip Code: ,Z
Qualifier's Name: `1'e j Lie. Number: & 00 /3 P��
Architect/ Engineer of Record Name: Phone#:
Address:
City: State: G Zip Code:
IADescribe Work: C "� f Cv Aty,- "
1 hereby certify that the work has been abandoned and/or,1he contractor/architect
is unable or unwilling to complete the contract. I hold the B jlding-O cial and the
Miami Sh res harmless of all legal rti I ` n
Signatur Signature
Owner or Agent / C ctor or Architect
The foregoing instr ent was acknowledged before mei �f� The fo egoing strumt Unowledged before me
this�day of Y1�,20A,by 65s �d/� 77/ this day of ? ,2W by
Who is personally known to me or who has produced who is personally known to me or who has produced
as indentification. as indentification.
Notary Public: Notary Public:
Sign: Sign:
COMMISION#M19045
e JORGE R Seal: :fir EXPIRES May 4,2018
MY COMM1SI 19045
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y 4,2018 (+0n 39b-0153 AloridallotaryService com
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