RC-11-535 Miami Shores Village
�Qz Building Department g p MAR 282011
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 L 9
Tel: (305)795.2204 Fax:(305)756.8972
V� -e_�L
,pJ INSPECTION'S PHONE NUMBER:(305)762.4949 B Y:
BUILDING Permit No. _ I — S�t)5
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: BUILDING
OWNER: Name(Fee Simple Titleholder): ( 1 Lf Phone7" ?a 357 / 'K�
Address: 9'0 Lei AJ 9-
`7 �Yl Y✓�C ._
City: f!r([C-cSi�.r. 6'110 bid State: jQz/Z(Dom' Zip:
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: l,) b JU-t ( r�►�c ,.
City: Miami Shores County: illmi Dade Zip:
Folio/Parcel#: afu y kCQ I on
Is the Building Historically Designated:Yes NO Flood Zone:
CONTRACTOR: Company Name: ' Phone#:3Us-_3�0
Address:� / Q 6�, / iiil , D A t� l • lA CI Pav1� �i, �� 1
City: . A, State: f3. r A , Zip: 313 30 9
Qualifier Name: V I.4-�p L k4v
Phone#:341 3 0!�-4 U ZL
State Certification or Registration#: LS-0 C141 J Certificate of Competency#:
Contact Phone#: D_-`106 0 , Z Email Address: b as j e:- Al"
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit: $ 2 , 3 o o Square/Linear Footage of Work: Z 1l0 V
Type of Work: ❑Address ❑Alteration ❑New )%R-pair/Replace ❑Demolition
Description of Work: m Oy P a-c-Q �v 11( 7 ��v4�� -bp p y t ,
Z-n sl Ay z) LJ /Ylf�oyV S
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
***************************************Fees************************ *******************
Submittal Fee$�ZD Permit Fee$ CCF$ CO/CC$
Scanning Fee$ 1 Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
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
constriction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING, SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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 isssulce,.otea'building permit with an estim to valu eding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construct 7ten� �irochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorlad�il�o �f commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building pe&41 is'issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature SlSignature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this AThe foregoing instrument was acknowledge efore me this-L
day of c,-,20 /D,by �Ni��6 ¢ rr day of w ,20(D,by u l f eY-- :lh9ffE-c ti o�.
who is personally known to me or who has produced Twi rL✓ who i rsona snow o me or who has produced
c-,-n 5-P As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: B N DY
=Public
Print:
My Commission Expire ,,o;PaY°�Br.
_� �� c State of Florida My mmiss j s: EXPIRES:",".k 02pires Dec 11,2012 e�y; BondedthroeghlstStatelnsurance
n#DD 844832h National Notary Assr,
APPROVED BY Plans Examiner -2�l '� Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)(rev6/4/10)