RF-07-2384kaiC ate.
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Nov 2 8 2007
Y.
Permit No. ` rOi (2b4
Master Permit No.
Permit Type (circle): Building Electrical Plumbing Mechanical
Owner's Name (Fee Simple Titleholder) AA ' /)20/S E
Owner's Address h5 9 / A.) IJ J hel,/
City Rl`T sgdr State
Tenant/Lessee Name
Zip 33 -
Job Address (where the work is being done)
Phone #
10w -i- hW acme-.
City Miami Shores Village /j County Miami -Dade Zip c ---c3)6
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company Name
Contractor's Address
City
Qualifier Name
Lbw, .1t7)
State
Phone #
4 _ e. to,
Zips . A
Phone #
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Phone #
.
Square / Linear Footage Of Work:
Type of Work: ❑Addition ❑Alteraticp N wI t 4epair/Replace ❑ Demolition
Describe Work: -4?A (,a('J S)C`' ` p / ). k 0
GOWAd ► - fo )5 )I ,
*************************************/*****Fees********************************************
Permit Fee $ / (/ ( .
Submittal Fee $
Notary $ •01)
Scanning $
Bond $
Structural Review. $
Training/Education Fee $ 0.20
D2
_ __ DPBR $
Code Enforcement $'�;
DEC 0 3
C,K ntoZ_
MIAMI SHORES VILLAGE
CCF $ , GD CO/CC
Technology Fee $ G.Sb
Zoning $
Double Fee $
Total Fee Now Due $ 111.30
• See Reverse side —+
'•
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEA1ERS, TANKS and AIR CONDITIONERS, ETC
414 V11't
OWNER'S AFFIDAVIT: I certify tall the foregoing i
Vinformation is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR1AILURE 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 inspecti.6h which occurs seven (7) days after the building permit is .issued. In the absence of such posted notice, the
inspection will not ee approved and a reinspection fee will be charged.
Signa'. e
a , 1 ntractor
The fore:oi g instrument was ac owi dged be= re me this oG The f. -I. ! Ins �'mez cknowledged before me this
day of • , 200J , by J Qi&e. , day of , 0 , by
o i personally known to me or who has produced who is personally known to or who has produced
s identification and who did take►��ath. as identificat . and who did take an oath.
4•5)V
NOTA' Y PUBLIC:
Sign:
Print:
,04GJ1N1' $ ,
0)\Zot 00 S4
ov
Gop, Geo
My Commission Expires:
APPLICATION APPROVED BY:
(Revised 02/08/06)
••''•.....la9
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Plans Examiner
Engineer
Zoning