REV-16-2536 PERMIT#
CONTRACTOR:
SUBMITTAL DATE: ( 1
ADDRESS: Lt
I R F-�
NAME:
v I
RESUBMITAL DATES: E¢
PROJECT TYPE:
ZONING PLUMBING
2-12
R CTU MECHANICAL
. . 12 2
ELECTRICAL ILDING
, IN
Miami Shores Village S P 1 4 20IG
b
Building Department
g p
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
\ / Tel:(305)795-2204 Fax:(305)756-8972
VI� \ INSPECTION LINE PHONE NUMBER:(305)762-4949 S�
FBC 20
BUILDING Master Permit No.OUS
PERMIT APPLICATION Sub Permit No \)I -
dBUILDING F--j ELECTRIC ROOFING Ej REVISION EXTENSION ❑RENEWAL
PLUMBING F-] MECHANICAL PUBLIC WORKS 0 CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I qO S4.
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): robPX-t C*Vh v Phone#: Ysr p'y
Address: 140 NW \10
City: KIAAS hu✓e -S State: T-(, Zip: 3 3)SCS
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: AMW UAK) S+O'r VrZXCC, *h) Phone#:'
Address: !080( Nk) 14 s ' yy
City: kIAJAi State: TL Zip: 331?Z
Qualifier Name:_, 01AINA-'AftLL) Phone#:
State Certification or Registration#: c6(, �.5 l3 Z-1 4 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ (500,00 Square/Linear Footage of Work:
Type of Work: ❑ Addition El Alteration
❑ New ❑ Repair/Replace El Demolition
Description of Work: Ke jACt comfN1k heiOe,,r 'CU paj-,( GS Qe,( vAs FetA cw
Specify color of color thru tile:
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 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 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 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 r Signa e
Owner or Agent Contractor
.� 11
The foregoing instrument was acknowledged before me this /.� The foregoing instrument was acknowledged before me this
day of425j�,20 LL,by KO 7l✓d 104E A) day of ,20�,by EoA) eJ�Ar,,?fie 2,
It
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: ,410, Sign:
a°°�P" `B��> ♦``pY PU,a NATHALIE DIAZ I'
Print: 8c d as - Notary Public-State of Florida Print: a�
rida
Commission ;r FF 230936
M Commission Expires: )� N9P P°° My Comm.Expires May 14,2019 My Commission Exp' s;N, aQF
Y P o'Foo. °,c My Comm.Expires May 14,2019
Bonded through National Notary Assn. ° Bonded through National Notary Assn.
C�
APPROVED BY Plans Examiner Zoning
PStructural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)