RC-13-2102IV/ IO/GVIO IV.40 rnA
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Miami Shores Village
Building Department
low N.F.2ral Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305)756,8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit: Type: BUILDING
)
JOB ADDRESS:
City: yiartti_Sii(Av„F_ County:
Is the BuildingHistorically Designated: Yes NO
OWNER: Name (Fee Simpie C.) "' r ,C.::.•
fit t ,
City:
Tenant/Lessee Name:
Email:
FBC 20
Permit. No. 2-1
Master Permit No.
ROOFING
_V
_Zip: . • I'
Flood Zone:
State:
_Phone#:
CON:FR.ACT()R: Company' Name: :r„. C.- ( ,
• 4.;„, I, 2 .-t•'• ";"
• "
Address.
stmt.: 4.- (
Qualifier Name: \ • ....A e •••• •
StPhone#: . -1
State Certification or Regigration .(7%) „C) Certificate of Competency tt:
Contact Phoneti: Address:C. -3 ,t
•
DESIGNER: Architect/Enginecr: .
Plionetr: .
„
-
Value of Work for this Permit: $ 2 .t)
1)tpe of Work: ZiAddition , CIA Iteration
Description of Work: L..
Square/Linear Footage of Work: 21- i.
LiNew °Repair/Replace ODemolition
Color dim tile:
. . 41******
Submittal Fee $ __ Permit Fee S
Scanning Fee $ Radon Fee $
Notary $
Training/I-duration Fee S
Double Fee $ Structural Review $
Fees
CCF $_
DBPR $
Technology Fee $
....—
TOTAL FEE NOW DUE $
CO/CC $
Bond S
1.0/ ICl/ L V I J IV . V V I nn 1 UV,*
V V J I J V v
!landing ('nenpany'r: Name (if applicable) .
litlnding Company's: Addre'r:r:
City State
161
Mortgage lender's Name (if applicable)
Mortgage Lender's Address
f.'itY Stare
'Lip ,..,.,
Application is. hereby made 11:1 obtain a permit to tin the work and installations its indicated. l cenify that no work or installation has
commenced print• to the issuance of a permit and that all work will be performed to meet the..: tandards of all laws regulatinr
coustructu:rt :n this jurisdiction. I understand that a Neparate permit must be. secured for ELIXTRIC'A;� WORK.. PLUMBING. SIGNS,
tkrl= A.S. POOLS, 11,IRNAC'l;?`, BOILERS, HEATERS, TANKS aril AIR CONDITIONERS, LTC
OWNER'S AFFIDAVIT: 1 certify that all the foregoing inhumation is accurate and that all work will be done in compliance with all
applicable laws regulating construction roti zoninh.
"WARNING: 7'0 OWNE.R: YOUR FAILURE, TO RECORD A NOTICE OF
(`OMMENCEMEN1' MAY RESULT IN YOCrR PAYIfNG TWICE FOR
IMPR()VEMIENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING., CONSULet' WITH YOUR LENDER OR AN A T TORNEY BEFORE
RECORI)ING YOUR NOTICE OF C ()MMENCF,MI NT"
NoliCe.' 10 Applicant: Ax a condition 1(1 the ismaru e trf o building; permit with on estimated +alar. eav:rediny $251,10, the applicant muse
promise In gr,od fRith aim r, copy of the notice of commencement and Con.egracrion !ie'rr law br ehure: wrlll be delivered to the pervon
%wins. property i.r subject 10 anachmcnl. Also, a certified copy al the recardcd notice of cunlntence'1ncnl ner.vt be pasted 4:e1 the .1.011 .rile
for the first inspection which occurs xeren (i) dura' after the buildiny permit is icstred. !q the• absence 0.1 such rusted 'loner, the
ilt.rpernen; will not hr•: up/n'r,I:r;d-and.A. xenupection fee will he Charged.
i
Signature • • ..
Owner tir Agent
The fort)ioing in tru►nent was ac.klulw'ledIA:d h.LS00-riu: tbli• 1 .
II IP
day 011..if.::�tt
_. off 1 `ti,J.Sv } 4'..' r .
per`grrtalliknown In me or whn has producedt' !
1. e
c.i 1' ri, i :. ;'; : ZAA idcr:t.ifiCatign and who did take an oath.
NOTARY4/1 BLIC::
Print:
My Commission Expire
Signature.
C.'ontr'actor
''
The fe.>fegving imarunumt
was;,e.knuwItfcl 1ebr!orcrneith,is
'
day0, C:a lr',O ,r het/...%..1•-•%•'"....`•fie!(i'(Ir1 '1 e i t'1'!y
a:herU pet onnlly known to.jhc or who has produced....._....._.___.
.....rte-
. • .3< ulentrficatron and who (lid take an oath.
NOTAR y PUBLIC:: ;
I.
%
r �
Sign:
j,
Print:
My Commission Ex,
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A.PPROVED Ti
Plans Examiner
Stntctural Review
rHcrised:ili2ret111:1N1tevisoillihn/(isakevir.e<tix,f orisamiteviseti1+15,09)
- Zoning
r'
Clerk