REV-16-2521Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 7624949
FBC 20 4
BUILDING Master Permit No.12 n 1 C- 250_9
PERMIT APPLICATION Sub Permit No.—E't 16 - 252
El BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION El RENEWAL
❑PLUMBING ❑ MECHANICAL El PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: • 1DG
City: Miami Shores County:
Miami Dade Zip:
Folio/Parcel#: // . Z / 3 I •- C $ U ® / C.)
Occupancy Type: Load: Construction Type:
Is the Building Historically Designated: Yes NO
Flood Zone: BFE:
FFE:
OWNER: Name (Fee Simple Titleholder): 61 /4/ 6,961 r ? G S- 75.-4;‘ s� / 3rd
Address: Z- es' 9 71 r 7
City: /// '`'/ 54;`,0/7/.7.� State: L
Zip: 3; l?c'
Tenant/Lessee Name: Phone#:
Email: VA/.41 ."4,-74 /to -"-//'s - e -
CONTRACTOR: Company Name: Phone#:
Address: \\ 5 £-
City: ri \ 15--1 ! State:
Qualifier Name: �(T 1 -17--
State Certification or Registration #: 7d' • 31`3
DESIGNER: Architect/Engineer:
Address:
Phone#:
Zip: -TS ►��
Certificate of Competency #:
Phone#:
City: State: Zip:
Value of Work for this Permit: $ �o / O o
Type of Work: ❑ Addition ❑ Alteration
Description of Work: CZ:"--/ ►
Square/Linear Footage of Work: 6 `N
❑ New
D Repair/Replace El Demolition
r -o 2 ` i 1 is. a 1-'7 (Z 7f ft
Specify color of color thru tile:
Submittal Fee $ Permit Fee C -Q CCF $ CO/CC $
Scanning Fee $ I.
• CO Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ i 2-0 - 01/43 Bond $
TOTAL FEE NOW DUE $ 2- (0 C,,,,
(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.
OWNER or AGENT
The foregoing instrument was acknowledged before me this
/.°' day of ,C�' b , 20 /r_, by
J Pst kartA(/l�j/t , who is personally known to
me or who has produced// f 2i t as
Identification and who did take an oath.
NOTARY PUBUC:
Sign:
Print:
Seal:
Ai too
I ; ogvIN:OLd�,•, JIM D. PAMPLIN
Notary Public - State of Florida
N9jy) sot,z.E7 My Comm. Expires Jan 13, 2017
avv.k•Commission # EE 864892
PP
Signature
CONTRACTOR
The foregoing instrument was acknowledged�before me this
day of /�' �z`f 'L_- , 20 /(7 , by
(`j/C th2fS(ae?who is personally known to
me or who has produced
F— Zi-- as
identification and who did take an oath.
NOTARY PUBUC:
Sign:
Print:
Seal:
**ss********s**s***ss*ss**MS `ms**************s*s******ssss
APPROVED BY
(Revised02/24/2014)
Plans Examiner
af I
Oef
qui
JIM D. PAMPLIN
Notary Public - State of Florida
My Comm. Expires Jan 13, 2017
Commission # EE 864892
***
Zoning
Structural Review Clerk