REV-17-162 25 Miami Shores Village REF
J
Building Department 201710050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 By: _
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 201 f1
BUILDING Master Permit No.,&../) 2,01,oq3 P
PERMIT APPLICATION Sub Permit No. V t , n —(b Z
BUILDING ❑ ELECTRIC ❑ ROOFING mt REVISION ❑ EXTENSION [:]RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
��p r y�T -y ,�J CONTRACTOR DRAWINGS
JOB ADDRESS: '7 FS5 !!'L .!� /y �J'!I lif�/ff�' SfJV?jX- '
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Tittleholder): aW,*V eS1,11A/�� hone#:6?-/"7�5o
Address:92-Fe )G -Al
Ty ?l/
N
/ iq �/ 5*�� State:
City: ;;PZ Zip: -3-2/x7olcp
Tenant/Lessee Name: Phone#:.1/a4 t?Cta
Email: ` �/� Imo. �^
CONTRACTOR:Company Name:�D�S 7; 7100- 46 UZG.D Il=`� Pho�ne��J !937' ??0
Address: 3&I A6 .367tY Al le T/Z�k
City: Al P,>/ 1/Q} State: TL Zip: 3434PO
Qualifier Name:GU Z�7W 9 A��Aff f Y Phone#: gos!!Pa9
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alter tion ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: _o�U "-r 01 i(J ���
N � ✓ .� amu.,
Specify colorcolor thru tile:
Submittal Fee$ Permit Fee$ S CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
00
TOTAL FEE NOW DUE$
(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 permitis , u . In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
SLSignature Signatur
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged b or me this
dayof JCA-A0C ' 20 (4 byI(Lday ofs-F V1UCL1[ 20 14 by
j b ti�y"a who is personally known to G us}w p -,y—
Yp ,CL ,who is personally known to
V i a T --�
me or who has p(oduced - 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:
Sign: Sign:
•,1Y PV• _ Y .NA GE pEI
Print: s�Z�tO�tarY I�Qa Print: da
•. .•; yComm.expires Sep 30,2018 •, ••e Comm.Expires Se 30,2018
Seal: '• , A:� Commission�FF 164325 Seal: ;y �:
'-.;o�r��;�•' , Q.• Commission FF 164325
�•�•• Bonded through National Nutary Assn. ��'•� p,��;dS``
Bonded through National Notary Assn.
****s*s****s*****s**s********** •* *r***********s******************s*•s*****s***r****************s**********
APPROVED BY Z3 L Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)