REV-16-2929Miami Shores Village
g Department
d venue, Miami Shores, Florida 33138
795-2204 Fax: (305) 756-8972
E PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
OCT 2 7.2016
:.J
FBC 20�y
Master Permit No. L C 1 ' / .(3
Sub Permit No. P) E V / iD ®Zq aq
®BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION 0RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1 fid aJ 1 Qat ST
City: ili Miami Shores County: Miami Dade Zip: 5313/
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ? ioP C (,C_ Phone#: '4& 10Z-
Address:
0 -
Address: 3j4 tv
City: 1•l.l 1
State: Zip: 351 64-
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Ji Lt.e.___ Phone#: -146, 3.ri S3-3'0
Address: 46, 4.111) 3i, N- r
City: i`1;AA-N. State: R__ Zip: 33 17, -)-
Qualifier
V_Qualifier Name: —0 k S® CA -016- Phone#: G, at -`:V S /g3
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: 1?( C • t -t40 u a'1 Phone#: //
Address: 10'A5 5 1412 Gov el City: II; State: r• 1.- Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: C t Of AOOA Solfrue (4 <tJ 41O K.S 2, 410v
9r
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: 1 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 abse ce of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of (, t' , 20 I , by
, who is personally known to
Signature
CONTR'CTOR
The foregoing instrument was acknowledged before me this
La' day of OOOJ - , 20 L' , by
who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath.
NOTARY PULIC:
r
CIA
�COMMISSION �' �QUEL ALEN7o1
,r.
Sign: • t;r': EXPIRES July 27, 2019
Print: 1 , .4
153 ?mty arvIce.eom
Seal:
identification and who did take an oath.
Seal:
************************************************************************************************************
APPROVED BY
(Revised02/24/2014)
Plans Examiner
Structural Review
Zoning
Clerk