REV-17-822BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
❑PLUMBING ❑ MECHANICAL
JOB ADDRESS:
City:
J
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
27
7
BY:
STA
QFBC 201
Master Permit No. r✓ — 12 — 1 l /
o' 33ZG
Sub Permit No. Y gZ2
❑ ROOFING ❑ REVISION
❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
IGS �t
❑ EXTENSION ❑RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
Miami Shores
County:
Folio/Parcel#:
Occupancy Type: Load:
Construction Ty e:
Mia
i
ade Zip:
Historically Designated: Yes NO
Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder)laY- Phone#:
Address:
ALV
City:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address:
YIV1/4_G
x'( 20 p t- -
City: 'ltaw.. 511ov.'7
Qualifier Name: clv \PC��a
State Certification or Registration #: CS---(..- 1 2-11 S
Vtck-OV `31,1C -C
Sta =:
DESIGNER: Architect/Engineer:
Phone#:
51-1-1 ' 6531
zip: e
Phone#: C C 3 ' VI
/G1
Zip: 3 5 Y3 '
Phone#:C
Certificate of Competency #:
Phone#:
Address: City:
Value of Work for this Permit: $
Type of Work: ❑ Addition ❑ Alteration ❑ New
Description of ork:
State: Zip:
Square/Linear Footage of Work:
❑ Repair/Replace ❑ Demolition
1. • 'At- ) •; 0.1..,A.,
i . � V•/ •\ • S
Specify color of color thru tile:..:.., -
Submittal Fee $ 1 Permit Fee $ 9- 5 CCF $ CO/CC $
Scanning Fee $ 2_ • Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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
OWNER/or AGENT
Signature
•
\ CONTRACTOR
•
The foregoing instrument was acknowledged before me this The foregoing 'instrument was acknowledged before me this
y of( YC*l , 20 r4
1 e.� by
T , who is personally known to
me or who has produced aZO l 12� 4 '--/.0 24as0
identification and who did take an oath. 4''t4} i P t�,�
�1��
/`::?r!e.
I!et�i
Sign:
Print: ,'!F
Seal:
******************************** *****
APPROVED BY
2 � day of i `r t✓1K-1' , 20 t' r• , by
bOy PGrCcle _ , who is personally known to
me or who has produced p (0 3 2 - ZCj I ;ZCCSLO
identification and w 'id take an oath. (-tor (d 1 t C .LJm
NOTA ;t!r.1! 1
le* -
Sign:
Print:
Seal:
************************************************************
n
Plans Examiner Zoning
Structural Review
(Revised02/24/2014)
Clerk