PL-16-614BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
PLUMBING ❑ MECHANICAL
JOB ADDRESS: 90 NE 104th st
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
..r.
.r'TiVTED
MAR 0 8 2016
FBC 201-1`
Master Permit No -P) lb—. 6) 14
Sub Permit No.
❑ ROOFING ❑ REVISION
❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
❑ EXTENSION RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County:
Miami Dade Zip:
Folio/Parcel#: 11-2136-013-0860 Is th uilding Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type: f / / Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): EV Rine
Address: 90 NE 104th St
Phone#: 305-804-6528
City: Miami Shores
Tenant/Lessee Name:
Email: evanrpine@gmail.com
CONTRACTOR: Company Name:
Address:
City:
Qualifier Name:
State:, rL
State:
KekVe l? -6117 2i
I
State Certification or Registration #: ,c/eD Oa t. Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address://.,,,,,��0 City: State: Zip:
Value of Work for this Permit: $ S 5-0 - Square/Linear Footage of Work:
Phone#:
Zip: 33138
Phone#: g0raj 7/,31
Phone#:
Zip: 3-17(5'
Type of Work: ❑ Addition ❑ Alteration ❑ New
*,?4_ � �D
Description of Work:
Repair/Replace ❑ Demolition
A/
Specify color of color thru tile:
Submittal Fee $ `4!, Permit Fee $
Scanning Fee $ 3• 0 V Radon Fee $ 2. 0 r)
Technology Fee $ 3- 2-0 Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ 1/41
DBPR $ 2. a
CO/CC $
Notary $
0.80 Double Fee $
Bond $ .� 0.01
TOTAL FEE NOW DUE $ 6 <-/ C)
L-63. YO
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address Central Mortgage Company PO Box 395
City Little Rock State AR Zip 72203
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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
[ day of ifIkardA. ,20 16 ,by
CIJIAM Qt (t , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
ANL ANL
•"" a KEMBLE ETTRICK
tbi.,
• Notary Public - State of Florida
•= My Comm. Expires Sep 19, 2017
P Commission # FF 055732
' or F%Ps Bonded Through National Notary Assn.
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of i�' l , 20 IL , by
+(4 �e. � i)' , who is personally known to
m who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
NCO N
v o A `/
N 51s
Leo
N M
Sign: 2 o Z
Print::.,. ... __
�coIt I%
Seal:. _°,� c Notary Puouc - -, ,. - ? g.
"ftw• s2
i -
•I. My Comm. Expires Oct 23 ... v r
;c Commission # FF 136597 i
`•P„'„;•�•` Bonded Through National Notary Assn.
*
or*
e�*ins*T**************
**********************************************************
APPROVED BY
(Revised02/24/2014)
Plans Examiner
Structural Review
Clerk