REV-16-2775 Miami Shores Village OCT 13 2 16
Building Department BY:
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 20jq
BUILDING Master Permit NoA C I - l( - l 0
PERMIT APPLICATION Sub Permit No. to -1(0 - Z.:;"9-J
❑BUILDING ❑ ELECTRIC ❑ ROOFING EKREVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBINGMECHANICAL ❑PUBLIC WORKS F-1CHANGE OF ❑ CANCELLATION E:] SHOP
� r� CONTRACTOR DRAWINGS
JOB ADDRESS: 11 -79-
/�L 'e 9
City: Miami Shores County: Miami Dade Zip: 33 (3 P-
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: 1 Construction Type: Flood Zone: BFE: FFE:
(
OWNER: Name(Fee Simple Titleholder): J C C j(f`1 MU sG Phone#: 5(.1)Sly -q sny
Address:
I��] 0M S k
City: w►IQM% 6(es State: Zip: S3 I SS
Tenant/Lessee Name: Phone#:
Email: Conn
CONTRACTOR:Company Name: �� /��(� ��> ��/"� /�`�� one#: �� f ���Tv
Address: S J-3.7' ! ,, /l
City: A4AZ6A) State: r`- Zip:, 3 r f
Qualifier Name: rh'5k4y j0A 0 2-- Phone#: 71'6 Z-� 1 S-Z
State Certification or Registration#: e, c /11'01 _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 p ❑ Demolition
Description of Work: Z-
•z eAq 6es A'%_ A Z PA M Z_
Specify color of color thru tile: ^�
Submittal Fee$ Permit Fee$ -r CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
00
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$250b, 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
OWN R or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of (Z)Cto bc- 20 s-�o by "2--day of OC-Toa-t7Z_. Q
Nr eAV
E by
�
'2 '1 � fes.r ,who is personally known to QL[�V �CL1�o►
1� PD� ��is persona(lyknown
me or who has producedl)L-6 210•V�y 9y-Z9q o as me or who has produced �L. � � bopaj as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY BLIC:
Sig EL Sign:
Print: �tv. t ✓ ,Cj V0 Print.
Seal: 04i ,dO
LENER CASTRO Seal:
MY COMMISSION#FF093479 rt,& P(�®4(, Notary Public State of Florida
EXPIRES:FEB 17,2018 Sindia Alvarez
Bonded through 1st State Insurance Q My Commission FF 156750
Fix res 09/031201
910312018
*************************** ******************** �*** ** ** * * * * **************
APPROVED BY U y� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)