EL-17-962 (2) .�.. .. ...�.v
7BY:
r IDBuilding Department AP`! 4 3 20117
10050 N.E.2nd Avenue, Miami Shores, Florida 33138Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 /_T
FBC 20 l J
BUILDING Master Permit No. - X223
PERMIT APPLICATION sub Permit No. F1 �a- 962__
❑BUILDING 0 ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
1 1 CONTRACTOR DRAWINGS
JOB ADDRESS: l ` N To1�--�'(/J
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: �`/��C �-b S•�� ' �Z�D Is the Building Historically Designated:Yes NO
Occupancy Type J Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): � TSG Y (.l��l J Phone#: OkJY7
Address: AA -,1�,A� '',,1G we)
//�j'�
City: l_l�/ State: V'y Zip:
Tenant/Lessee Name: V (�L �-tLl,� ll A� Phone#:
Email: On T��l� NA
S �
' �� •( Ver Y l
CONTRACTOR:Company Name: /"< < 2�S �l2 ���f A ����• Phone#: �79'����•
Address: 45�3 7 D TE,eW
City: y'-//*,a'4 /• / �' State: �L zip:
Qualifier Name: 144;1 y Q [ ' �Q y Phone#:.3 6 gL9a3!7
State Certification or Registration#: eel 7 g l Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$'/�,f���• Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration C ❑ New I ' ` I, Repair/Replace ❑ Demolitio
",,
Descpt o 0
ri i n f Work: r( J W6yv. K S V
� r
Specify color of color thru tile:
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Submittal Fee$ Permit Fee$ 7� •t1 CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee
Structural Reviews$ Bond$ i ' �6
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.
Signature Signature
OWNER or AGENT CONTRALTO
The foregoing instrumeat was acknowledged before me this The foregoing instrument H as acknowledged before me this
da of 2 by day of T r by
w o is personally known �&e-1 / -r- 20 1A/•,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 PU NOTARY PUBLIC:
Sign: Sign:
Print: Print:
Seal: GEORGETTE BLACKBURN Seal: .Ye GLORIA C TRIANA
* * MY COMMISSION 1 FF 202094 •'e MY COMMISSION#GG010165
EXPIRES:June 13,2619EXPIRES July 10,2020
N1'FOF FLY Bonded Thru Wget Notary Servica • '
308-0163 FIOrMlNOtefySlIVIC9.00In
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APPROVED BY �`/�PIL /�' Plans Examiner Zoning
Structural Review Clerk