REV-17-1135Miami 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
IR
�� FBC
BUILDING �. t it No.
PERMIT APPLICATI N ISO ot pub Pernit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING
ELUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: lJ ,e(),?'.Slf i G
City: Miami Shores
❑ REVISION
❑ CHANGE OF
CONTRACTOR
CEIVED
APR 252017
SS
201q
2C (3- Zt02-
p,Ev
❑ EXTENSION ❑RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
County: Miami Dade
Zip: 3.3/ 3�
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):
Address: 9.~
c=
Construction Type: Flood Zone:
NO
BFE: FFE:
Phone#: [ 307 216 -Z7S'Y
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 3y 6 W/-&-. Phone#:
Address: c/
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $
Type of Work: ❑ Addition ❑ Alteration
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace n Demolition
Description of Work: Rev re. c= //,(, -,xt Dar A'!,f /14F}N'U.F-c9c7'va«x-'"21-C c-71)IK'en Airs
/IOD, �/ 7' CO,UA) c�-7 6 Z - -7lt-r 4 (7-D�Xi�?FIr�i C�32 �u i • %�. r
i •
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Training/Education Fee $
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE$ R'w
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.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
2..5 day of -PS( I
, 20 , by day of , 20 , by
°mar cctSso 1 cl , who is personally known to , who is personally known to
me or who has produced C ZC (0-(QCA 1-C 0 -C me or who has produced as
identification and who did take an oath. IOYl d_- identification and who did take an oath.
NOTARY PUB IC: (tc-e-/‘ NOTARY PUBLIC:
Sign:
Print:
Seal:
Sign:
Print:
Seal:
************************************************************************************************************
APPROVED BY
(Revised02/24/2014)
Plans Examiner
Zoning
Structural Review Clerk