REV-16-3443 Miami Shores Village
tvek Building Department 7BY: ��
16
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 201Lt
BUILDING Master Permit No. WS 1 (40^ 2 ZS Z- Z
PERMIT APPLICATION Sub Permit No. P�'� \,/ I ro"
❑BUILDING ❑ ELECTRIC ❑ ROOFING ( REVISION ❑ EXTENSION [—]RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: h �( .�/IN > ST
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER:Name(FeeSimple Titleholder): T)Q1/1 i �a5r'(- Phone#:
Address: A ilk/ Ct
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email: /
CONTRACTOR:Company Name: t' �`) l„dY16ty)GtrOh Phone#:
Address: 70
City: Al/0 a q1W l State: F' ( Zip: 3 �O
Qualifier Name: ;Er,'c ScarAorw4, Phone#:
State Certification or Registration#: C.��C S!S / / 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: ❑ Addiitio/n / ❑ Alteration ❑ New ❑ Repair/Replace ID Demolition
Description of Work: �l pl 1.�/�Cdr ESy✓
Specify color of color thru tile:
Submittal Fee$ U Permit Fee$ CCF$ CO/CC$
Scanning Fee$ — 1 Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
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 ccurs se en (7) days a r the building permit is issued. In t absence of such posted notice, the
inspection will not be approv and a r spection fee 1 be charged.
i
Signature � Signature
OWNER or AGENT CONTRACTOR
The foreg 'day
was acknowledged before me this The foreg Ing i rument was acknowledged before me this
2Zh� day of , ► )`_CWVn,O� 20 At by 22L`� day of !M ,Lr 20 by
77b cdv►ite CV01% A-r�S�a who is personally known to Gc JC OY6t>� who is ersonally known to
me or who has produced r1VY Y �C�hS� as me or who has produced �ht( K s as
identification and who did take an oath. identification and who did take an oath.
NOTARY qL - NOTARY B
Sign: Sign:
Print: Print:
Seal: � �'e;&•,, YANADY PRI 0 Seal:
MY COMMISSION#FF 214031
YANADYPRIETO
EXPIRES:March 25,2019 MY COMMISSION#FF 214031
€pF �.•
Bonded ThNNotary Public underwriters EXPIRES:March 25,2019
Bonded Thru Notary Public Underwriters
APPROVED BY Plans Examiner Zoning
'I Structural Review Clerk
(Revised02/24/2014)