REV-16-84704(161G
BUILDING
PERMIT APPLICATION
BUILDING
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
0 ELECTRIC 0 ROOFING
MAR 3 0 2016
'n' '.
FBC 204 sill _
Master Permit No. 84- - 2-15 - 5 Z7
Sub Permit No. v 1(40 "• 2541c -
RI REVISION ❑ EXTENSION ❑RENEWAL
❑ PLUMBING 0 MECHANICAL 0 PUBLIC WORKS ❑ CHANGE OF 0 CANCELLATION fl SHOP
14-0
j, CONTRACTOR
JOB ADDRESS: 1°2-G9 NE14
City: Miami Shores
County: Miami Dade
DRAWINGS
Folio/Parcel#:
or/0 oo
Occupancy Type: Load: Construction Type:
zip: 3 3➢ �'
Is the Building Historically Designated: Yes NO X
Flood Zone:
BFE: FFE:
OWNER: Name (Fee
Simple Titleholder): I4.) --A/ V S-1 Phone#: -(55 75 ' 6 3Z )
y
Address: 126 -I NE 4 5+-
City: Q I'Y� ( 1 10)'es' State: F L Zip: 3 �-A 1 3 ''�,
Tenant/Lessee Name: Phone#:
a
Email: i,y.2e_..`�Ei`,c r�� C'�C�dl�(¢%`�
CONTRACTOR: Company Name: Phone#:
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #:
DESIGNER: Architect/Engineer: ed77 v V
q� 9
Address: 186 5 7 I S+- C 5wy
Value of Work for this Permit: $
!ie,le
5 A
Certificate of Competency #:
� Phone#: `186 -5 zi-6 • 5046
City: N�O.13AVi V' i State: PL. Zip: 177 3 1 + I
Square/Linear Footage of Work: °'
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace (1 Demolition
Description of Work: h2 V 1 SC SYI le-' 5 1 2,e, •
Specify color of color thru tile:
Submittal Fee $ Permit Fee $."3 G CCF $ CO/CC $
Scanning Fee $ O Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ P)O (36 Bond $
TOTAL FEE NOW DUE $ 1) - 03
(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
OW R or AGENT CONTRACTOR
The fore:oing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 1-{ , 20 1 ' , by day of , 20 , by
1 /YlSwho,ls personally known to , who is personally known to
FC --)1A-2,.
me or who as produced ''3- Gab V3 '715'a -s74 `i me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: ,(1362.)z -,862-t_
Print: i4 9lJ�l2 ze-e- h71�
Seal:BMW ZEEMAN
MY COMMISSION N EE 860189
EXPIRES: February 15, 2011
,,,,,, pp4
e Boded Thru Budget Notary Senses
APPROVED BY
( Revised 02/24/2014)
Sign:
Print:
Seal:
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Plans Examiner Zoning
Structural Review Clerk