REV-16-1317 a RECR: 1\j ; F
Miami Shores Village MAY 16 2016
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)762-0949
FBC 20M S
BUILDING Master Permit No. 1ZC9-( 5-ZZgC1
PERMIT APPLICATION Sub Permit No.Ey I fol 1,711 1_
❑BUILDING ELECTRIC ❑ ROOFING ® REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 64 K30 q R 'ST--
City: Miami Shores County: Miami Dade Zip: �3a l J O
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load:
.SCo/nYis't/ruroct,ion Type: Flood Zone: BF�E: TZIF�IF
E-:
OWNERNaem (FeeeeSimple Titleholder): Jla222 s IClels Phone#:
Address: L'7 hk)
City: LA(Gm CI,,, YfS State: Zip: /
��� �1
/671111(o�r/7
�Tenant/Lessee Name: Phone#:
Email:
L-CONTRACTORCCompany Name: //,'IP('7Yi / C/S��es°S Phone#: /0 (o 4'1
7
Address: ff/7 0 o' S W ! 7 "� ;S Is-rev' ����---- r
City: State: /r' Zip ��s: 7p� /7-3
Qualifier Name: dio �" Phone#: 7Xl-`
State Certification or Registration#: Certificate of Competency#: E—=- '740",3
DESIGNER:Architect/Engineer: � `�,4-0CA4T�`e> Phone#: 305 OqG $7 00
Address: ( C.C�I� UQ--6E 't t" �O1 City: State: rL Zip: 301�-�"
Value of Work for this Permit:.$ r Square/Linear F,o(otage_of Work:
f Work: ElAddition Alteration
Type o ❑ New. u Repair/Replace ❑ Demolition
DC ascription of.Work:
Specify color of color thru tile: 01A."
Submittal Fee$ Permit Fee$ � ✓��.!tea CCF$ '� CO/CC$
Scanning Fee$ 3 - Radon Fee$ L1 -SO DBPR$ 4•Sy NotaryS.
Technology Fee$ Is •co Training/Education Fee$ 2-00 Double Fee$ "--�—
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 4 022
•10
(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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Sign ure Signature
O NER or ENT t CONTRACTO
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 by day of Gtr 20 / by
who is personally known to 5V / O who is personally known to
me or who has produced�A$R�cvas 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:
Print: .o ' , 1 Print:
+° ^z Commission k FF 897800 °
Seal: z My Commission Expires Seal: '* .; Commission FF 897808
�� My Commission Expires
March 12, 2018 ''�° °".�'� March 12, 2018
************************************************************************************************************
APPROVED BY f A 129 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)