REV-17-1421BUILDING
PERMIT APPLICATION
BUILDING
El PLUMBING
JOB ADDRESS:
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
❑ ELECTRIC ❑ ROOFING
REC P,Ts i5
MAY 262017
BY:
FBC 201-1
Master Permit No. (0 ' ZOO S
Sub Permit No. Rem 1-R -1q2_1
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ MECHANICAL ❑PUBLIC WORKS CHANGE OF
CONTRACTOR
90 N6 46 it c37
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County: Miami Dade
Zip: 3313
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load: Construction Type: Flood Zone:
OWNER: Name (Fee Si ple Titleholder): r'e (o /
es / `L c
Address: 2_ UI re(Ce U �/ ` dux 5u ZZ O
City: MA ( State: L
NO
BFE: FFE:
Phone#:
365-70? -9 e
Zip: 33 l 3
Tenant/Lessee-Name: Phone#: ►l
Email: fc, ( \' I O 72s (/G . C Ow/
CONTRACTOR: Company Name: 1-046.‘ a1A0.117Y Re'i8�o1 Phone#: 3� ''40:/ / -0353
Address: �) 1 ZZ 3f .Sup 12Sr 3t / 2/ 1
City: /4Laern1 State: ( Zip: 33/ otb
Qualifier Name: ECIA10.1(d Tod Phone#: 361469-o3 3
State Certification or Registration #: CGC- 1 Z v 35" 7 Certificate of Competency it
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑O/ Alteration i l New ❑ Repair/Replace ❑ Demolition
Description of Work: /4&..../,'74a",'"-) j SC2 / (A -ID A - /-274'70, /!!/77,0
/�2u) /T-7 6t) lU7'",/,0w epQX-/4r74 c42,//5 "2,66, %4//
Specify co r of color.t_h,u tile::"
.
'r .4 , I,
Submittal Feei,SO •, ' , ; to . Permit Fee$; �Q CCF $ 1 • .10 coicc $
r c
Scanning Fee _air ODBPR $ '2 Notary $ J 4 00
�
Technology Fee $ 1 Training/Education Fee $ ! V Double Fee $ fif
Structural Reviews $
(Revised02/24/2014)
7\\
Bond $
TOTAL FEE NOW DUE$ I 21 • 20
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
The foregoing instrument was acknowledged before me this
2-3Y6 day of (WO
, 20 f1 , by
4CC+krS • clke (Al O , who is personally known to
me or who has produced -br tV'er t 1CQ,f S as
identification and who did ta. - • . h.
NOTARY = IC:
Sign:
Print:
Seal:
************
••y,, Y „iYPRIETO
;= MY COMMISSION # FF 214031
if EXPIRES: March 25, 2019
. elf Bonded Thru Notary Public Underwriters
APPROVED BY
(Revised02/24/2014)
CONTRACTOR
The foregoing instrument was acknowledged before me this
at -A. day oL(O"-/ , 20 f , by
Zwho i personally known i
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
******************
Plans Examiner
Structural Review
mldrlle iRrch
•'.ar •'' MICHELLE PINEDA
Notary Public • Stale of Florida
—i •I Commission N FF 991421
fi. *MpOommAitifirIMMaa314410
**********
Zoning
Clerk