REV-16-3140 '7
Miami Shores Village "�7]13
NOV 16 2016
Building Department
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 20 Iq
BUILDING Master Permit No c-c '(0- 2. 19-2
PERMIT APPLICATION Sub Permit No. "� 8(0- 5 1 qo
❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP
GJ CONTRACTOR DRAWINGS
JOB ADDRESS: ! 0 2-
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:Nam (Fee Simple Titleholder): LLCPhone#:
Address: 6 Aj�
City: Y r `hie State: Zip: 1 I
Tenant/Lessee Name: L Phone#: JC, � '�;q Z SSq q
Email: yn0eyryl n�( ��.e��sye� .(-C,/-^
CONTRACTOR:Company Name: � i Z�Phone#: q,�—q
Address: t� �e� /5C��izlC, �Z 1�� • o,�iy/� ` /�y�f G
City: M!9 rVt i State: �� _ Zip:
Qualifier Name: 1�IAITOAJi'L-7 e'U W Phone#: ' S 3 ��3y
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: 6at F6h2`t t b Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ N�+�' ' Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New �] Repair/Replace ❑ Demolition
Description of Work: �t✓i1 Q 5 vOoU p L✓��jb c�E, ��(� Te n� 1.19���
F}C W12.bl�J 6 T-0 J -J.S peTV2 ey f7 T`/ 01= M,L4" �SI-a94E�PS,
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ 9:;P11 Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
®O
TOTAL FEE NOW DUE$
(Revised02/24/2014)
n
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 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 0 Signature
OWor AGENT CONTRACTOR
The fo egoing instru t is \Q
acknowledged before/me this The foregoing instru ent was acknowledged before/me this
1 day of 3 V C)\1R 1 -Z-C- .20 I v by day of ®�►°'ti 0 !�` by
vt rill �Zkl k .who i ersonally known to 40 n 1'0 D G+O,who is p onall nown to
me or who has produced as me or who has produced P-OL 0�0 304s
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: TARY PUBLIC: n
1)J
Sign Sign:
a ,c�- (r- 0-�0, e-
Pri VOW '�A e3 ar� Print: C( l-(\A C . lei
ORGI A.
.►�'P� DE LA ROSA Seal:
Sea ;�,o •,; ;o�;��gyp,, PlIARIA C.CAMARA
Votry
Public-State of Florida =a, +; MY COMMISSION#FF 14.'1623
mmissian*#�FF 9148019 * (PIRES:November 21,2013
%,;rF �•`� My comm.Expires Apr 29 .2020 "°'',F o'c °e' Bonded Thru Notay PuNic Urd:,vnftsrG l
APPROVED BY (�17Plans Examiner Zoning
'11/p lk Structural Review Clerk
(Revised02/24/2014)