REV-17-1833 Miami Shores Village
Building DepartmentL AJ
74J 2017
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(cf
BUILDING Master Permit No. 1z1; -to • ('1 . I S&1
PERMIT APPLICATION b Permit No.-2_ y� - F)30S
❑BUILDING F-1ELECTRIC ❑ ROOFING ❑ EXTE ON RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION
�
14 c� /`t' CONTRACTOR DRAWINGS
JOB ADDRESS: l 1 os oc AV
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): 1 )(A��u��k p�o f :v���A• Phone#: e}6� • (a Id 2/�{
Address: �0
City: State: Zip: 331 '�D
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#:
Address:
City: M, 6an j a Stater Zip:
Qualifier Name: 81Me�' Phone#:-79(-,, 42?) /n6:)
State Certification or Registration M(24iQ Z12-9,5.5 0 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
Description of Work: rl�a��r.��lc Gesso a til
Specify color of color thru tiler
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$
(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 t��t, �c in tarns as indicated. I certify that no work or installation has
commenced prior too h� is ance-of a permif� 4� r �lr performed to meet the standards of all laws regulating
constru l - tgt�ok�
i�i1 I f , ,It��understand t at a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNAC. 0 L�t l , TNkS,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'I mmencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a e ified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7J day after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspec on f e will be charged.
Signature Signature
WNER or AGENT CONTRACTOR
The fohregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of —TL.-"Ly ,20 [ � by I& day of :JM 20 k- by
,56X-C/o ✓Je✓-A"� who is personallyknownto A 1 q;tJ 170� t o LVL ,who is personally known to
me or who has produced/%C-J�(--U I Ga?16D I!-WIPO me or who has produced as
identification and who did take an oath. identificatio and who did take an oath.
NOTARY PUBLIC: NOTARY PU C:
Sign: Sign:
Print: Print:
Seal: •�
� MYC4M4IISS10Nplit30747if6 Seal:
WIWI:Apra 14,2021
• , . BOndedT9roA6oteryPabiClAldeRwlNs �#0°
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/ } µ 0910312=018
APPROVED BY _ Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)