REV-16-1664 < Miami Shores Village �� ;. .
Building Department JUN 14 2016
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305)795-2204 Fax: (305)756-8972 BY
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 (�
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit NogwIG
O'BUILDING ❑ ELECTRIC ❑ ROOFING En"'REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION a SHOP
'` /� f CONTRACTOR DRAWINGS
JOB ADDRESS: �a /�1�.�� —11'&C-
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): 2:A4 '63 `'3l� 0. - U�W6 $h ne#: Co 13 ?—
Address: oa ` 4- A41- QS1
City: K^-\�, State: F-L Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: L g C"aul C'*)b— I-&_ Phone#: 305 32
Address: ?f 23 r WvNE 4rC 'k--M3
City: �`� t1�e�u�ens State: Zip: 331 y
Qualifier Name: Phone#: 30.'S-6 l3 � -
State Certification or Registration#: -�—1-1 nI Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace •❑ Demolition
Description of Work: 1 �r�� � SM�,,p c�1 M�_ �t-i1 °+�� l .�tf
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CCF$ +� w CO/Cts
Scanning Fee$ I P
i- CO Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ 1Z0 W Bond$
TOTAL FEE NOW DUE$ I�
(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 la roc ure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of co mence ent must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. n th bsence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature `I ` Signature
OWNER or AGENT ONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrumen was acknowledged before me this
day of �� 20 C by I L( day of 20 U6 by
QZIS0 K@0L who is personally known to ��STAV6 Nl(�N ( �opersonally known to
me or who has produced as me or who has produced FL--tn II s-T Ll Q"As
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC- NOTARY PUBLIC:
Sign: Sign:
Print: Print: r.J>V-P,
Seal: �ExPkss
aiYPubNc t�bofFWWO Seal: #
trlcla Fag9lpnato o1vRY POQ, Notaro+'::r; State of=;'or
• commMW FF 9b680a r ^ Sir:oua P,ivarez
0311512020nAy Commission FF 156?q�► OF 4` Expires 03/03/2018
********* * **** ****** ***** ************************
J(9/64-Plans
APPROVED BY Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)