REV-17-625BUILDING
PERMIT APPLICATION
❑ BUILDING ELECTRIC
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
305) 762-4949
FBC 2014s
4-11
aster Permit No. EEN it — S %,'
ub Permit No. `i / •(p
ED EXTENSION ❑ RENEWAL
❑ ROOFING
❑ PLUMBING ❑ MECHANICAL [] PUBLIC WORKS
JOB ADDRESS:
❑ CHANGE OF
CONTRACTOR
5 NC ID5.s7gEE:r
❑ CANCELLATION
❑ SHOP
DRAWINGS
City: Miami Shores County:
Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: load:
OWNER: Name (Fee Simple Titleholder):
Address:
Construction Type: Flood Zone:
NO
BFE: FFE:
6'7 p Io ap;44( Phone#:
11 o r^ " -
City:
bc.c, State: •e•—
Zip: '331.
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address:
ao d- 2 LaC.
1 cb0 21 h1 W -11 CO L_(z-[
phone: 306 611050(01
City: k l ale/_�- State: W re___( 1-513r Zip: 230 1,
Qualifier Name: IA LA LA b i p 3' �li (% L 61 S Phone#: {�
State Certification or Registration #: Ef` O O Q
gil O Certificate of Competency #: 0600 / Li ZBZ
- DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ $ Square/Linear Footage of Work: ,u /4
•
Type of Work: ❑ Addition ® Alteration ❑ New 0 Repair/Replace
Description of Work: /"10 J-
G� G. 7 ec-4-yc 1 e< ( to ( <
❑ Demolition
Specify color of col thru tile:
Submittal Fee $ Permit Fee $ �.et d' 0 CCF $ CO/CC $
Scanning Fee $ • 0.7 Radon Fee $ DBPR $ Notary $
Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE =)e . G
Technology Fee $
Structural Reviews $
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 ha:
commenced prior to the issuance of a permit and that alt work will be performed to meet the standards of all laws regulatinf
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
• E EZSAFRDAVIT: I certify that all the foregoing information is accurate and that all work will be done in with al
applicable laws regulating construction and zoning.
PI,.
ING TO • ET d3 OUR FAILURE TO REDDRD A NO110E OF COM M B\IC M E T MA`
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTENE
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDINC
YOUR NO 110E OF COM M B'ICBUI B'fT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant MILE
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the persot
whom property is subject to attachment: Also, a certified copy of the recorded notice of commencement must be posted at the job`siti
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice,,thl
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
3 day of 61-u6..ri
h.M 5.04trrJ- , who is personally known to
me or who has produced as
CONTRACTOR
The foregoing instrument was acknowledged before me this
, 20 ti , by I day of ( -doly.,i d 20 `r
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
L�ICIA M PELEGRIN
Y COMMISSION #FF1188Q01
EXPIRES November 23, 2018
(407) 398-0153 FlorldallotaryServlce.com
by
personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
P>`2-e-vfr-e-
Inn 393.0.53 fy;detlofNyitw,109,78 ._
upOuirrhaiiir
lei MY COMMISSION # FF911879
EXPIRES August 23, 2019
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APPROVED BY
/4i4"friL » Plans Examiner
Structural Review
Zoning
Clerk