REV-17-2336BUILDING
PERMIT APPLICATION
El BUILDING ELECTRIC ❑ ROOFING ❑ REVISION
El PLUMBING D MECHANICAL ElPUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
X22 t. 1bO s7 -
Miami Shores Village
Building Department
10050 N.E.Znd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
Questions/Comments/Concerns ?
Monique Smith, 786-253-2869
sPP»
FBC 20
Master Permit No.
JOB ADDRESS:
City:
Lc�I
Sub Permit No. Re. Nt
Miami Shores
County:
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
Miami Dade Zip:
Folio/Parcel#: 1s the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �//"T L) V ( Pr 1-4-04t 1 k Phone#:
Address: '22( NL 100 S T
LLC,
City: I'• S 1-k2 (LCS State: F
7 ' b W3 2069
zip: 3a)Cs
Tenant/Lessee Name Phone#:
Email: %(,4 IVk QV( SM 01-1-e PCT. NE -r
CONTRACTOR: Company Name: bYIW 1) /1' E<�Ll LIC'1 iNG
Address: 5 rP OA/LV L et 2-- l
City: A4/41-4 1 State: F/
Qualifier Name: —i 0 3 NT 0 S.
Phone#: ,?c : ••z(% o t
Zip: 3.30/6-
Phone#:S'7),S l Z S -
State Certification or Registration #: ECS /3(206_62/ Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ J ® Square/Linear Footage of Work:
Type of Work: ❑ Addition
� p❑ Alteration El New
n' ElRepair/Replace 1 IDDemolition
NE- "
Description of Work: 1 0 c� cS i o W Aiz Z L AA)/ N6
-\,bl,S" IN1 GT7tt 04-P-)c-T&Z--( vQ p44 L ,S I S' 'l
�- P t Nit fi Q uitVC / IQ 6 POW ems.
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 45",--4%;,‘',e' CCF $ CO/CC $
Scanning Fee $471 • 03 Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ e ,' " GO
(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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the fi t inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection n. be approved and r: inspection • will be charged.
Signatu
The foregoing instrument was acknowledged before me this
215 day of 3C,p + , 20 1-9 , by
e
is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Si
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
, 20 IE , by
day of
Vt/i 1 Q , who is personally known to
me or who has produced t 1 ICrS� as
identification and who did take an oath.
Ayiny.k, MARARAI K. GONZALEZ
EXPIRES: November 2, 2020
Print:
1:benauitulur9 Pm ii 6/1 - i =rs
Seal:
• ONZALEZ
Stii ;' �: MY COMMISSION # GG 044602
�`.a;
EXPIRES: N
'•.;p� .�o$.•` �� o1'ember2, 2020
Bonded 7 tvu Notary Public Underwriters
**** *********lit************************ Y********** i***************k*+f<****iii*********iii#********* t►*******
APPROVED BY
(Revised02/24/2014)
39SA7dr Plans Examiner
Structural Review
Zoning
Clerk