REV-16-1319 R
ECEIVED
Miami Shores Village
Building Department10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 .(
FBc 20 ly s
BUILDING Master Permit No. w'-cl' ks^
PERMIT APPLICATION sub Permit No.K-(-V G — FS ( F1
❑BUILDING ❑ ELECTRIC ❑ ROOFING dREVISION ❑ EXTENSION ❑RENEWAL
91P'LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
/ J �y� CONTRACTOR DRAWINGS
JOB ADDRESS: 64 Nw OA STr-
Cit : Miami Shores County: Miami Dade zip: rJ�
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): T�I� ���-� Phone#:
Address: 86 ofa loq �T
City: 1f..0 h4'A( �µO�---E S State: T=L Zip: ��l
Tenant/Lessee Name: '-VA Phone#: c
Email: Tnt'1 @ � � �N• CAO-4
CONTRACTOR:Company Name: (O V PL � M Phone#: az�
Address: I L4-Lr L.F '�• L^/ 12- g' K c
City:—IA tr � Iff,, State: Zip: rJf
qualifier Name: S�evxc.uTny✓a✓4 riy! Phone#:
State Certification or Registration#: Certificate of Competency#: C'F L 14 i S( 0,6
DESIGNER:Architect/Engineer: -FFEU 6C0 At:—:�OciPhone#: --30'5 ZqG 8700
Address: (:°WCW25E- 3'01 City: E� State: FL Zip: 53+S4•
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition I
Alteration ❑ New [�(Repair,/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ ( I CCF$ CO/CC
2 $
Scanning Fee$ 7 • Radon Fee$ DBPR$ 4 .2Ir Notary$ ,Pb
Technology Fee$ Q Training/Education Fee$ 9" Double Fee$ Cp1�
Structural Reviews$ _ Bond$ `nCJ
TOTAL FEE NOW DUE$ ✓ O�
(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.
Signatur Signature !!•
O ER NT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of k&y 20 1 by day of 91 20 ib by
who is personally known to i?,i?AU who is personally known to
me or who has produced /',�Q' ��.�' 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:
Print.• ..' '
Print:
Commission# FF 897808
5
_• • Commission#FF 897808
Seal: My Commission Expires Seal: :,
z� My Commission Expires
°j"11W March 12, 2018 of Vt°r`'�� March 12, 2018
APPROVED BY '( 1� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)