REV-16-2295BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
ONE NUMBER: (305) 762-4949
REVISION
PLUMBING ❑ MECHANICAL ElPUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
t, 0 SC `L
JOB ADDRESS:
CPrcrpD,I
ANUG 1 5 2016
I
D� p.
� Y
FBC 201
rmit No. 2C 1 Z
ermit No.W1 t L 29.9S
❑ EXTENSION
❑ CANCELLATION
❑ RENEWAL
❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
zip: \
OWNER: Name (Fee Simple Titleholder): `P CZ' ""-\
Address: 1 tO 5(c, Jr G S � il C
Phone#:
City: ,jc (filt \ (.1. 6-4_12,- State: i
Tenant/Lessee Name: Phone#:
Email:
Phone#:"3a•1 -r �)z7
Zip: 3034
CONTRACTOR: CompanyName: \T t c c _ 0 �" �� O
s v -
Addr ss: z- 511 � 17 Lot to �j`F 4
City: row' c .4 0 1B-QQ2 L�- State: 1 1' Zip:
Qualifier Name: FeA C— IT k1 Phone#:
State Certification or Registration #: c� OG a k.fin 9 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $
Type of Work: ❑ Addition ❑ Alteration
Description of Work:
'PO IC 1 i•'� V
Square/Linear Footage of Work:
❑ New
❑ epair/Replace
cr- IA
Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ -1 S `'L- -' CCF $ CO/CC $
Scanning Fee $ 3 LC) Radon Fee $DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $5°C)
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 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 �.'/�O L Signature
OWNER or AGENT
CONTRACTOR
The foregoing instrum nt was acknowledged beforemethis The foregoing instru ent was acknowledged befor, me this
day of 20 ` " , by l fI day of �, , 20 / 1 , by
, who is personally known to GRIC Pr carets TevgAinio is personally known to
me or who has produced
identificatio
NOTARY PU
Sign:
as
Print:
Seal:
syr vup, UURAFARlE1
�° •••,�, c MY COMMISSION $ FF 188027
.4 EXPIRES: Match 16,
2319
a
BOW Wu Budgot Hari
me or who has produced as
identification and who did take an oath.
NOTARY P .1 IC:
Sign:
Print:
Seal:
a
491 Zko LAURA F
* MYCOMMISSIONSFF1':,27
EXPIRES: March 16,2019
"544.x, Bonded Thru Budget Notary Services
******************************.***-***ix*******************************************************************
APPROVED BY
(Revised02/24/2014)
Plans Examiner Zoning
Structural Review Clerk