REV-17-2195BUILDING
PERMIT APPLICATION
D BUILDING
[PLUMBING
JOB ADDRESS: -t KNJ
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
❑ ELECTRIC ❑ ROOFING
LJ MECHANICAL PUBLIC WORKS
City: Miami Shores
3-L
FBC 20) �- J
Master Permit No. 2C - ) - I3—. 96
Sub Permit No.-- )
J REVISION EXTENSION ElRENEWAL
❑ CHANGE OF D CANCELLATION El SHOP
CONTRACTOR DRAWINGS
County:
Miami Dade Zio:
Folio/Parcel#:
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):
Address: V40 9 $ , �, �i Q
City: Kcttm
Is the Building Historically Designated: Yes NO
Construction Type: Flood Zone: BFE: FFE:
&,31 e 2i LXi? A9nles( ,Cp Phone#: /5,-1- ,7 L(--14I
`'Y
State: I Zip: 331 GO
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: L
Address: (35Si 5%-4) 1‘10 ASV
12)L504. n5Se eee5 ,(cPhone#: 30S'. - 3(-r65y
City: VwCo,rini State: c 1 Zip: 33 i etC
Qualifier Name: £1.61 P ziCl'L14 Phone#: M - 35' -G81(,
State Certification or Registration #: CFC 054, /-55- 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: \,'(l
Square/Linear Footage of Work:
D New ❑ Repair/Replace
OA-( y9lcr,l.e- S
❑ Demolition
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 $Th ‘..0 ` e
(Revised02/24/2014)
r
r
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 commence nt must be posted at the job site
for the first inspection which o : urs seven (7) days after the building permit is issued. In th - ab ence of such posted notice, the
inspection will not be approve; f +nd a rel ecti fee will be charged.
Signature
OWNER or AGENT
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
/ 6' day of A 0,5A I- , 20 O , by a/ day of 4- , 20 1 - , by
00 41.1 MD j Z (,2 2 , who is personally known to
me or who has produced - Ls • asp
roduced
Chiftt ULWl' W , who is penally known to
me or wo has
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
m'
Er
'ildY COMMISSION 07291944
MAY 12, 2020
lit Stale Insurance
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
MY COMMISSION #FF991944
FIXIMISS; MAY 12, 2020
NOP IiiFBjgg 1st State i -c, rance
as
************************* *********************************.*******s****.*f**.***.********s*.***********
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APPROVED BY
(Revised02/24/2014)
Plans Examiner
Zoning
Structural Review Clerk