REV-17-2285 (2)BUILDING
PERMIT APPLICATION
5
BUILDING ELECTRIC ❑ ROOFING
0PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: ` 1V E '01
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
Master Permit No.
RECEIVED
SEP 2 21011
FBC 20N
ZC 2050
Sub Permit Nola -6,V 19- Z'ZB.S
REVISION ❑ EXTENSION Ei RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip: 331M
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): J 0245 L,11-eal
Address: / l WI it/ C (0 `C 56
Phone#:
706 cr7 35
City: 1 \,i »A --*h a S Lt $ ✓l7
State: (2Z-- Zip: 33 (�
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: --%' ✓ er74
Address: .iJ awl ,s, '1 X`,,r,
,r ,C --1,''4.1,'-j ,.. LA D
City: /3.: ),/ K.!_ f : ' J State: f % Zip:' . ,
C✓<;`, \1;,/ i�' j/.'! �1P', Z. a ' :
Qualifier Name: ��
Phone#: i ice/ P •
State Certification or Registration #: 6 IL. ('-1-')'•4! 1SZ2 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:%� City: State: Zip:
Value of Work for th' Permit: $ 0 Square/Linear Footage of Work:
Type of Work: Additi n ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
C-)itAmn5 k br — cx- OC an& red- Nr 1v
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ `60 CCF $
CO/CC $
Scanning Fee $ O Radon Fee $ DBPR $ Notary $ '
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ C7v / GO Bond $
TOTAL FEE NOW DUE$ O
(Revised02/24/2014)
Bonding Company's Name (if applicable) �V /
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 . reinspection fee will be charged.
f
Signature
OWNER or AGENT
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this The fgregoing instrument was acknowledged before me this
�i ��
-'(�! day of , 20 ` _ by (�` day of G" 1"' M , 20 \19 , by
���, who is personally known to G(CX\ ' r41CA LS , who is personal known to
S
me or who has produced as me or who has produced �' (, S -M4 personally
CC,Aeas
identification and who did take an oath.
NOTARY PUBLIC:
identification and who did take an oath.
NOTARY PUBLIC:
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SILVE,����i,,
4
Sign: �, ON 4°Sign:
Gr6, 20 (.0
Print: ;opo `� Print:
Seal: s :2 014)r;o¢ Seal:
i • 9******"*"*************:**,*()L,r.f;;;.;'.111/8.1"6:1on\tg'•6:::********************* * *******************
'
MARIA CAROLINA DUQUE
Notary Public, State of Florida
Commiselonll FF 949226
My comfit: expires Jan. 10, 2020
APPROVED BY
(Revised02/24/2014)
r
Plans Examiner
Zoning
Structural Review Clerk