REV-17-830 ` I7 017
Miami Shores Village ; CMjAR
_
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tal:(305)795-2204 Fax:(305)756-8972
INSPECTION UNE PHONE NUMBER:(305)762-4949
FBC 20-f 2
BUILDING Master Permit No. S _ -9 38
PERMIT APPLICATION Sub Permit No. Yi�-y 1 k:�i,
�UILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL
❑PLUMBING ❑MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR � f�DRA�WINGS
JOB ADDRESS: /to�� Nt� 5f � ^� u � 1 .
City: Miami Shores County Miami Dade ZIO' /;�p
Folio/Parcel#: _ _Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: SFE: FIFE:
OWNER:Name(Fee Simple Titleholder): G�/�/5 T/� ��iVuEJL Phone#:
Address: l 1 IVC
City: t State: Zip:
Tenant/Lessee Name: !_ Phone#:
Email:
CONTRACTOR:Company Name: /'L C= >r�y7TB A/� �ifij.L� phone# �7�/' 74k;C-
Address: l
City; LkrlState: Opt- Zap:33rwl'o
Qualifier Name: •L/r/d/[D� (��=�Or- Phone#: -j6x- 7.4y- wok
State Certification or Registration#. �J LG/3/�f/!6/7 Certificate of Competency M
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
DSlpti o _ +
L Wv-
Specify color of color thru tile.
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ _
(rtsvisedo2n4n014)
1 °
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$2500,the applicant must
promise in good falth that a copy of the notice of commencement and construction lien low brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted of the job site
for the ftrst inspection which occurs seven (7)days after the building permit Is Issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
SignatureSignature
—�9/
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing Instrument was acknowledged before me this
2�- day of MQ yY�(C� ` 20 [� ,by /� 15' day of f'� h / 20 I'7 ,by
1 aC.l personally A d' C � fl ,who fs personally known to
�/� who�i7s erso/�nall known two Ar,-,)lt• .. CeL.c �
me or who has produced SCOO r JIM-1 bQ I`Ja�� me or who has produced ----/
` -- as
identification and who did take an oathr�qt(i y0Q 03-identification and who did take an oath.
Y NOTARY PUBLIC:
Sign: Sign: ,w� ,s \\\\\\\I111111t!//l�trhAnn J- ////
MAMAJItId q
Print: = MY COMMISSION#GG 044602 Print cri ECP iii
,• :;r November Z.ZUZU = . p
Seal: %F'o';"0 Bonded Thru Notary Public underwriters Seal: ;
' /SAD
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APPROVED BY Plans Examiner yr�tr:LII; Fi i$
/d7j^71+;. fit,•,:
Structural Review Clerk
(Revised02/24/2014)
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