REV-17-358 Miami Shores Village
Building Department �Z13
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 F7
Tel: (305)795-2204 Fax: (305)756-8972 BY:INSPECTION LINE PHONE NUMBER:(305)762-4949 F/BC 20
BUILDING Master Permit No. 1� - n610
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELEC RIC ❑ ROOFING ❑ REVISION ❑ EXTENSION E]RENEWAL
❑PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
p� CONTRACTOR DRAWINGS
JOB ADDRESS: I�o 3 �� 11w
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 Titleholder): l I,L Phone#:_ v}' � -22-2,z�
Address: n Jnr' q s H bel
City: State: � Zip:':i�i DR
Tenant/Lessee Name: r Phone#: a_C—W) - 1210
Email: 21
CONTRACTOR:Company Name: �av�/4/I�-tom 1 , Phone#:
Address: /n� ,,�,
City:��: `L,� (�'�flC� State: Zi
Qualifier Name: ns? (j qfi� Phone#:
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 Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: C(,4qc��
R..y"1T" _F,, ...n,,. O:<ti,.:.�h2g` 9tr �".' ".4c a,! '" w-t •)
Specify colortof color thru tile:' :_
Submittal Fee$ sial!Rr�rh�jsrs, -P�rmit Fee$ I r CCF$' "' "- 'L CO/CC$A
amu..
Scanning Fee$ 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 comm t must be posted at the job site
for the first inspection w ict►-F�ecGrs- days after the building permit is issue n the sence of such posted notice, the
inspection will a approved=and reinspectio Fee will be charged.
natur Sign ture
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this Th foregoin strument was acknowledged before me this
f<3 day of rAv Gl 20 1 7 by day'of 20 l 7 by
w o is personally known to c, who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PURL
sigh Sign:
Print: Print: eq,µ
ELI 4MM ELORRLIGA
Seal: Seal:
. MY COMMISSION 0 FFI»36369y, Andrea Ditkltein
ar EXPIRES January 25.2= ' 'A `rs Comrroission = 5G0231101
140i)3"-0•%,J Fbrftrloh 3ww.*ca ' Expires Augis,21,2020
APPROVED BY i 1 Pans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)