PL-17-1646 (2)BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
PLUMBING ❑ MECHANICAL
JOB ADDRESS:
#16"
City: Miami Shores
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
F (
ii BC 20 i
r
Master Permit No. I I la 1 t:�
Sub Permit Not6 `I �
❑ ROOFING ❑ REVISION EXTENSION ❑RENEWAL
PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
❑ CANCELLATION
❑ SHOP
DRAWINGS
County:
Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: R E5 Load:
OWNER: Name (Fee Simple Title/h�older):
Address: 495- Ai( 7EiJ
1�i rn� 6/.MPs
City:
Construction Type: Flood Zone: BFE: FFE:
fi2/t-lau DO Oct/
Phone#: 9/ 9- 370 --10,5-33
State: /7L •
Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: POOLS 44 C.C. 6r. Phone#: I7 , 132 - OcIV
Address: / Z 3/5- .S GJ La 3 cl'
City: ///%�M j State: /f -j_. Zip: 3 3/ ,Q 6.
Qualifier Name: �� i 11 PV /-to es(T V ► u `e L • Phone#: 7S& - 732 069/y
State Certification or Registration #: c pc ,i/c-- sog Vs' Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City:
Value of Work for this Permit: $
Type of Work: ❑ Addition n Alteration New
Description of Work: JGcJ/ IL4/4/ ;Ji 1900 L f-71 cl 5) 1i.)j
State: Zip:
1,.000. Square/Linear Footage of Work:
❑ Repair/Replace ❑ Demolition
n �•
+l. ;h
Specify color of color tliru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Permit Fee $
Radon Fee $
Training/Education Fee $
(Revised02/24/2014)
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE$ (86 .3
Bonding Company's,Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's_.Name-(ifapplicable)
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
c2 —day of /?9A/7' ,20 /7 ,by
//'►')/970/0 tl Z , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
AIDA PEGUERO
* MY COMMISSION 1 FF 165583
EXPIRES: October 5, 2018
reoFwie>° Bonded Thru Budget Notary Services
as
Signature
The foregoing instrument was acknowledged before me this
2-2 day of Hae—CH- , 20 / 7 , by
i‘ ll-er�-eo 4)0/ J'e` ; who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
AIDA PEGUERO
* MY COMMISSION 1 FF 165583
EXPIRES: October 5, 2018
+rF0F,09. Bonded Thru Budget Notary Senices
************************************************************************************************************
APPROVED BY
(Revised02/24/2014)
Plans Examiner
Zoning
Structural Review Clerk