WS-15-1010 (2)5‘A6
(kifkk 11\ -
BUILDING
PERMIT APPLICATION
.71.BUILDING D ELECTRIC
❑PLUMBING ❑ MECHANICAL
JOB ADDRESS:
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
FBC 20 10
Master Permit No. WS 10
0(
Sub Permit No.
❑ EXTENSION ❑ RENEWAL
❑ ROOFING ❑ REVISION
❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
IJP
D CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County:
Miami Dade
Zip:
Folio/Parcel#: 1 — 213 (p — OO Cp — O ' O
Occupancy Type: Load:
Sec4fo,v ltt4.c L
OWNER: Name (Fee Simple Titleholder):
Address: \ ka 01/4.1 't \O \°
Construction Type:
Is the Building Historically Designated: Yes
Flood Zone: BFE:
k 3"3
NO
FFE:
Phone#: (3c6) i R 3 1
City: 0- a. S\Vo e_cc
State:
Zip: 331�j�j
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: 33 SO \7
d Q m�0 r� \K\ vJS Phone#:.365 3 6!-f 79 S
City: Stat
Qualifier Name: C__CD
State Certification or Registration #: �� 5 0
DESIGNER: Architect/Engineer:
Address:
T;=' t, 5 ` 6.6 is 4 Ph`one#:
1 4, ?ti e
a Zj Certificate of Competency #:
Zip:
0 l2
Phone#:
City: State:
Value of Work for this Permit: $ 4 12, 7 do Square/Linear Footage of Work:
Zip:
Type of Work: ❑ Addition ❑ Altera' n ❑ New Repair/Replace i-4, Demolition
Description of Work: • �� g,- loo
Specify color of color thru tile:
Submittal Fee $ ' Permit Fee $ 260 • a)
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
, •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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
The foregoing instrument was acknowledged before me this
day of /Orr/ , 20 /-C-
t
CONTRACTOR
The foregoing instrument was ackn%wledged before me this
by % % day of /4 (.5r , 20 (s , by
�+ T �'fr , who is personally known to VOL.. / pE? , who is personally known to
b
me or who has produced as me or who has produced as
identification and who did take an oath.
identification and who did take an o- J) v, I « eq -t.-5(
NOTARY PUBLIC:' NOTARY PUBLIC: ����p11111i1100
("7..
Sign:
Print:
Seal:
My (- Fxpires May 17, 2015
C # EE 94962
Borden i„ tonal Notary Assn.
Si: n:
Print:
Seal:
3
I moo
•********************$**************,***********.*****************************i***a**.*********.************
APPROVED BY
(Revised02/24/2014)
04/
!�
Plans Examiner
Zoning
Structural Review Clerk