RC-13-868 (2)BUILDING
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
3 Y.
JUL 2'SZOi4
FBC20 11\_,
Master Permit No. A 'i 3 �3
Sub Permit No.
❑ BUILDING
❑ ELECTRIC
❑ ROOFING
n REVISION
❑ EXTENSION
❑ RENEWAL
PLUMBING
❑ MECHANICAL
❑PUBLICWORKS
❑ CHANGE
CONTRACTOR
❑ CANCELLATION
❑ SHOP
DRAWINGS
JOB ADDRESS: , 11 Nr- 1O . sk
City: Miami Shores County: Miami Dade Zip: U:A
Folio/Parcel#: t`—Z (36'x'1 ^eagc.
Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Haase_
n� Flood Zone: BFE: FFE:
i -I
OWNER: Name (Fee Simple Titleholder): &QI G Sr Phone#: ) 05 L Q
Address: a NV 201- Si"
City: C ij Stara
e
State: -c‘
Tenant/Lessee Name: Phone#:
Email:
Zip:
CONTRACTOR: Company Name: CCA CoAskcut6trk k 1 t1` Phone#: Z-11- .
Address: a Ao fame- ZC[ �#
City: 14(ta_vv1(•
Qualifier Name: C.Q4cgS FeaciCk
State:
Zip: 1 -el
Phone#:
State Certification or Registration #: 2-011103 E Certificate of Competency #:
DESIGNER: Architect/Engineer: PeJtaiN Styaar, pmt Phone#: JS 2322A 53'
Address: tL23% 7L( t City: IAi.:014 A State: TC Zip: 'PM -
Value
Value of Work for this Permit: $ 0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: 1 '., . fi n 204 4CAS.S•es con A 60zols fecleaLkeovAnk®'C
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ GL4 • 03
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 w..ich occurs seven (7) days after the building permit is issued. in the absence of such posted notice, the
inspection will not b - a p • ved and a reinspection fee will be charged.
Signature V
wner or tient
The foregoing instrument was acknowledged before me this
-v z_
who is personally known to me or who has producedTCVCAYtatki
WJE As ident fi4 i anSAINactkaK... RooRicuez
_ MY COMMISSION # EE053785
a•,���
EXPIRES January 09, 2015
(407 •:-0153 FloridallotaryServicccom
NOTARY PUBLIC:
Sign:
Print: &) 0/(C.ii
My Commission Expires:
Signature
Contractor
The foregoing instrument was acknowledged before me this d
day of 30 `'1 , 201g_, by COO IDS Silva ,
who is personally known to me or who has produced Pr5cYJJI4.l
1C.iNcZ.0A as identification and whn raid take an oath,
oi`�". BARBARA CRISTINA RODRIGUEZ
NOTARY PUBLIC: _* '* MY COMMISSION # EE053785
alt �:
��;o°' EXPIRES January 09, 2015
398-01 3 FlondallotaryServicre com
Print:` iYQ., •
Lrt Za
My Commission Expires:
***********************************************************************************************************
i
APPROVED BY
7/1(`C f Plans Examiner
/-142riPY
Zoning
Structural Review Clerk
(Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)