REV-16-864BUILDING
PERMIT APPLICATION
Miami 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) 762-4949
Master Permit No.
Sub Permit No.
❑BUILDING IlrILECTRIC ❑ ROOFING al6ISION
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS fl CHANGE OF
CONTRACTOR
JOB ADDRESS: /' f /
FBC2O(u
Cli-44
AG- -_zs
12_0116-86*
❑ EXTENSION ❑RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County: Miami Dade
Zip:
Folio/Parcel#: 1/ Z/ c7 1 c7
Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: C 4 S Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): C/' //1 Q/ ic,41. y S'C t r ✓vPt, Phone#: a 5 7 cc 3 / ?sem
Address: 2(% V .4,/.f.7--9,— 5 7
City: /11/0i/7/ S //vim f State: E C
Tenant/Lessee Name:
Phone#:
Zip: ? ? / ? cc'
Email:
CONTRACTOR: Company Name: a 67.71 C-:-• /
Address:
City:
i /.12) s /Air ,
�7State:
Qualifier Name:4(', _6..4/ jzS
State Certification or Registration #:
DESIGNER: Architect/Engineer: CIO/ 2-Y/
Address:
7i 4,(Phone#:
Oe w- 402
Zip: ,330/
Phone#:
Certificate of Competency #: /
Value of Work for this Permit: $
Type of Work: ❑ Addition ❑ Alteration
Phone#:
City: State: Zip:
Square/Linear Footage of Work: 2
❑ New
❑ Repair/Replace ❑ Demolition
Description of Work: , I� /�
7�. e �1 6 %1.J 4 ft/' /9
Gj /' ?®Uesl�
kr-/HES
Specify color of color thru tile:
Submittal Fee $ 0 Permit Fee $ CCF $ 0 , Go CO/CC $ 0
Radon Fee $ P-5 DBPR $ -5 Notary $ O
Training/Education Fee $ 3 - Double Fee $
Bond $
TOTAL FEE NOW DUE $ 6
Scanning Fee $ L3
Technology Fee $ 0 • 00
Structural Reviews $
(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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged. �1
ER or AGENT
The foregoing instru (�e�t was acknowledged before me this
14 day of I 1 ca" ✓� i , 20 __ is ,, by
V Ii v V;) 0 U cel cab i ersonally k
me or who has produced •�
identification and who did take an oath.
NOTARY PUBUC:
Sign:
Print: Ci C 1M i
Seal:
Signature`
CONTRACTOR
The foregoing instrument was acknowledged before me this
2 day of )' / -1?-- , 20 /6 , by
to!EL C /64"--/z / , who is personally known to
as me or who has produced i k7 47),— as
identification and who did take an oath.
NOTARY PUBLIC:
p Sign:
V a C 0F1C- .e Print:
•""""'"'" Seal:
�'o� r Z, NAOMI VASCONCELOS
;: --il I MY COMMISSION #FF088554
Lvt$ice iiii PS EXPIRES February 2, 2018
*************** ****101Fllalli9tiitjdflI tUgh***********Y*****************iY********* i************** ****
°,,,,,,''
SANDRA E PENNY
0ioeeNotary Public - State of Florida
My Comm. Expires Apr 24, 2018
ommission # FF 116240
APPROVED BY
(Revised02/24/2014)
/t Plans Examiner Zoning
Structural Review Clerk