REV-16-2800Miami 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
RECEIVED
OCT 1,7 2016
BY: ex-
FBC 201 41
EV[IS1Qt"b BUILDING �°. `��� � Master Permit No.21013
914
PERMIT Sub Permit No. 1htV (0' 2600
❑BUILDING ❑ ELECTRIC ❑ ROOFING Ei REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 2.4-1 Mil V__1 511.Eti
City: Miami Shores County: Miami Dade Zip: 33 f c(,
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name
lIV(Fee Simple Titleholder) :! iT (4 I�t i C TER E ! t Phone#: Sv �(� i��( - 4 6 7 z_
Address: 2.41 w J 2 t'(3 3 I itis f
State: .T4 -01(Z r Zip:
City:
Tenant/Lessee Name: Phone#:
Email:
53i3o
i
CONTRACTOR: Company Name:62 d/(Z4 5p14,,7,
b. i)Af
Address: cr kQ j j e' l/( s r
City: 13e5vioyitAt p Az. L4 State: 17wi,
Qualifier Name: 1 t��eI �o/Gt3 Phone#:
State Certification or Registration #: f'J►CCn 0491q-31 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
State: Zip:
PholftiG 4¢3• 8 siC
zip: 33/ /
Address:
Value of Work for this Permit: $_Cird 00 'oV
Type of Work: ❑ Addition ❑ Alteration
Description of Work:
City:
Square/Linear Footage of Work:
❑ New
Repair/Replace
n Demolition
zau � J . se 4114 a Two r miz cm, .
v ki c to sr rpo xi pip -e I 'ni t3. a s
Specify color of color thru tile: .,�r�'
Submittal Fee $ Permit Fee $ �O0'�� CCF $ CO/CC $ �-/
Scanning Fee $ i-' • v �I Radon Fee $ '1 . Sb DBPR $ CI • 50 • Notary $
Technology Fee $ 9 • Training/Education Fee $ I • Double Fee $
Bond $
Structural Reviews $ -
(Revised02/24/2014)
vo
TOTAL FEE NOW DUE $ 3 Z 3
, -
Bonding Company's Name (if applicable)
Bonding Company's Address
City ' State Zip
Mortgage Lender's Name (if applicable) _
Mortgage Lender's Address -
City r ,' State ( + Zip
a
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 ofcfObeV /
, 20 , by
M -f -i Io
, who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Signature
CONTRAC •R
The foregoing instrument was acknowledged before
me this
/,�I/ I day of n I,Y , 20 / , by
T(�IC.0x i/c( -.1 C' S , who is personally known to
as me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal:
ANA PARRILLA
: Notary Public - State of Florida
My Comm. Expires Apr 21, 2017
Commission # EE 867787
Sign:
Print:
at,t4 e
Yr`1C�
Seal: ; o•P" ANA PARRILLA
' 7 �., Notary Public - State of Florida
+ r_in :zi My Comm. Expires Apr 21, 2017
'; 04 4V ,. Commission # EE 867787
******************** ***, ,k************************** ********
11
APPROVED BY
(Revised02/24/2014)
Plans Examiner
Zoning
Structural Review Clerk