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���� Miami Shores Village
k-A)c*-tC 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
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC DZOFING
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: 1 09 0 NE 9 < V P.;1
City: Miami Shores
County:
NOV 6 2015
c4
FBC 20 it
?f cs— 2S
Master Permit No.
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
i3O ,,
❑ CHANGE OF ❑ CANCELLA1I_O,N I,
CONTRACTOR
DRAWINGS
Folio/Parcel#: i ( 320.5. 027- O/ / O
Occupancy Type:
Load: Construction Type:
Miami Dade Zip: 33 1 3 c(
Is the Building Historically Designated: Yes
Flood tel e►.n d
NO
FFE:
OWNER: Name (Fee Simple Titleholder): M 1 OiM1 yip Z v 1 ev\) t .i . C. Phone#: 3crS-7% f- Si Li -S-
51" •
&5f•
Address: •7 217 /VC 02 -
City:
2
City: M 1 Gt NA/l+ State: Zip: 3313 t
Tenant/Lessee Name: Phone#:
Email: (r // p
CONTRACTOR: Company Name: U ben I/ CQ /� CJD
/fry Ori S i I • Phone#: ()S 8.Z -g—,) ty,S
Address: ?QW si,f.i 1'L-/ G -f- •
City: (M\ a 1M I State: •FI' 1 (I ��= LZ
Qualifier Name: M 1 ch ov-e 1 r Cl 04 iron • Phone#:
State Certification or Registration #: CCC 1328Y 1'f & • Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Square/Linear Footage of Work: Z7
Er
1t; -
ZIQS )
Value of Work for this Permit: $ 1/ 0D0
Type of Work: ❑ Addition ❑ Alteration
Description of Work:
r
New
Repair/Replace
b
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ 50 Permit Fee $ �33 .CA
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ • 0
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 co _o fement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. 1 +i41 tit o s ch wasted notice, the
inspection will not be approved and a reinspection fee will be charged. y , ., f,_
OWNER or AGENT
The foregoing instrument was acknowledged before me this
/3 day of 'ove4.,Jsc . ,20 ✓.r • ,by
,', f4 60 P Jere • , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
,, Pta,
MY COMMISSION # DD 2
ORLANDO HIDALGO
Pu.lIc Underwriters
Signature / _ �--
CONTRACTOR
The foregoing instrument was acknowledged before me this
'J day of isOOrVG0.1s L�.r,,a,. , 20 /J . , by
,44l44,.,e ®fie alre., . who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY P
Sign:
Print:
Seal:
;. My COMMISSION #DD 1,:.
- EXPIRES: November 7, 2,
bonded Thai Notary Public Linde
0/an a�
•****************e************.*•*************s********************s*******M***M*************************
APPROVED BY v` / Plans Examiner Zoning
Structural Review
(Revisedo2/2412014)
Clerk