REV-16-1239 NIP ED
0�'� �E�EIV
Miami Shores Village �gY092016
1� J
V Building Department sY.
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 1+
INSPECTION LINE PHONE NUMBER:(305)762-4949 �T—
BUILDING
FBC 20 1 q Master Permit No. Qc' l2•��— 3/ 6,
PERMIT APPLICATION Sub Permit No:!?J�:O ( C - 1239
✓BUILDING ❑ ELECTRIC ❑ ROOFING )n,REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1 2—Jd
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type:
pp�� Il_Flood Zone: BFE: �( /FFE: `-�]��
OWNER:Name(Fee Simple Titleholder): -r DLV;WSJ � aqi ` 3 Phone#: 3y IO�3 V•�1–� L
Address: I" �k ?2-001 �' � o
City: ,�t��� 4� �� State: – Zip: 3313 6 .
Tenant/Lessee Name: Phone#: ,
Email" &kkb 15UA Phone#:,,,,tom
CONTRACTOR:Company Name: /�,
(vim kkb
Address: `fes(Z� W-rc4` YJr 41003
City: jc>m lam V i�lara 6 State: �'Z_ Zip:
Qualifier Name: fen9\fir /b, 'y�o�: p Phone#:
C6
State Certification or Registration#: C. 113(-(-r I + Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: . per City: State: Zip:
Value of Work for this Permit:$ "f`"'� Square/Linear Footage of Work: ZQQ z-1--
Type
iType of Work: ❑ Addition [ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work L
OUst.
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ ( QJO . GJ) CCF$ CO/CC$
Scanning Fee$ 3 •,�,��n� I Radon Fee$ 'c�" 0 1 DBPR$ Notary$
`
Technology Fee$ �1 . 90 Training/Education Fee$ ), 2-0 Double Fee$
Structural Reviews$ 0 Bond$ 0
TOTAL FEE NOW DUE$ 19 18 . (%
(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 lue ceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien I broc re will be delivered to the person
- -whose-property-is-subject-to-attachment.-Aliso,a-certified copy-"e-recordedwmice-ofc mence errt-must-b�-pest-eft-the jdb-fit-e-
for the first inspection which occurs seven (7) days after the building permit is issued. n thea ence of such posted notice, the
inspection will not be approved a reinspection fee will be charged.
Signature Signature
ER or AGENT ONTRACTOR
The foregoing i str m t was acknowledged before me this The foregoing instrumen was acknowledged before me this
_day of /_ 20 (( by `' day of ,20 NO by
C1Ito who is personally known to 641q)D4'0 Q�OPCX,i who is personally known to
me or who has produced as me or who has produced as
identification and who ke an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
,N
Sign: " 1 Public Stat of Florida
Sign: �M°' Notary PubNc S e of Florirte
Print: c ° Nly Commies on F 956808
Print: ` Ay dommisrion .F OV-31)8
a t<
Seal: Seal:
APPROVED BY �`� �'� l�' Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)