EL-17-2206Miami 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
BUILDING
PERMIT APPLICATION
❑BUILDING 'ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL 1] PUBLIC WORKS
JOB ADDRESS: 1 15 D N t 03 6-1--
ECE 1..V (
avG'3i1lou'
FBC 20 (L-1
Master Permit No. R ^ 2207-
Sub
202Sub Permit No. el 2?C)CQ
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores Q County:
Folio/Parcel#: [ — 3205-0 �"t — D125D
Occupancy Type: Load:
Miami Dade
Is the Building Historically
Zip: 33 / 3 L/
Designated: Yes NO
Construction Type: Flood Zone:
FMLXbgv ui�rJ l_ _ r
OWNER: Name (Fee Simple Titleholder): M �cs'7 � 1�it , IJ C/
Address: 1c 122 NE 1 (04 5+
�p
City: N. 1 b4 \\Wal OgtsU/(,
BFE: FFE:
Phone#:'30- 2A9(9ZOtp7
State: FL Zip: 331
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company NName .ICOY1 E ted—k, ,1V\C .
Address: k.D (� JV�\\.Aa
��\ E -z»:\^_
City: U-e.c' c'�\ekd vC--\/‘ State:
Phone#: lSLVfl - S ll(S
Qualifier Name:"—St"-L5 VAO-C,()V C\M'(
Zip3 3 l L
tt,� Phone#:Zi\)'' t 1 5LiLk5
State Certification or Registration # E CO() o\3 31 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $3 000
Type of Work: ❑ Addition 7_1Alteration ❑ New ❑ Repair/Replace ❑ Demolition
PLS
Square/Linear Footage of Work:
Description of Work:
GC:4
�i1�It ilU l.^i
'11171'P,
Specify color of color.#hru tile:1 rr: •v•
"•'." v ,T',',.;r'.14a.5,"• /1 %311
Submittal Fee $ Permit Fee $' "CCP ea, b CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 1 i I ' 515
(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
promise in good faith that a copy of the notice of commencement and construction lien law brochure will
whose property is subject to attachment. Also, a certified copy of the recorded notic: o c. mencem:nt
for the first inspection which occurs seven (7) days after the building permit is i sued. the a•sen.
-
inspection will not be approved and a reinspection fee will be charged.
$ 500,
e deliv
ust be
the • pplicant must
red to the person
osted at the job site
h posted notice, the
OWNER or AGENT
The foregoing instrument was acknowledged before me this
CONTR CTOR
,r
The foregoing instrument was acknowledged before me this
— I
, 20 11 , by day of 30* , 20 -7 , by
T5 i tc e-5 c v-C\14t-e , who is personally known to
me or who has produced [),LJ1(\ as
identification and who did take an oath.
NOTARY PUBLIC:
/{� day of
d H)11(4)1\, who is personally known to
me or who has produced 044 r-3.14-1V2rlas
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
u�,MY COM S i H FF151364
'00F,` EXPIRES: August 14, 2018
0 �.
Sig .►��..�. � AVASNIVria
BEVERLY DROUILLAR
Print:
Seal:
9.ft4', Beverly Brouillard
COMMISSION 4FF244352
x' EXPIRES: July 11, 2019
%;rEgF' �o`� WWW.AARONNOTARY.COM
"nnu�a��
************************************************************************************************************
APPROVED BY
(Revised02/24/2014)
31/}-41/ j'Plans Examiner
Zoning
Structural Review Clerk