EL-17-527 Miami Shores Village � � �
Building Department APR 8 2017
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10050 N.E.2nd Avenue, Miami Shores,Florida 33138 '
Tel:(305)795-2204 Fax:(305)756-8972 BY'
INSPECTION LINE PHONE NUMBER:(305)762-4949 t.
FBC 2014
BUILDING Master Permit No. �' y 1 -1 —1(n I
PERMIT APPLICATION Sub Permit No. , 3�i7" 5�7
❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL
` ❑PLUMBING ❑ MECHANICAL ❑PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION'
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1u CONTRACTOR DRAWINGS
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JOB ADDRESS: I N W q J 3f,
City: Miami Shores County: Miami Dade Zip: ..3 3 1 r0
Folio/Parcel#:- Is the Building Historically Designated:Yes NO
Occupancy Type: `Load: Construction Type: Flood Zone: BFE: FFE:
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OWNER: Name(Fee Simple Titleholder):_ _�O r t.
l�l Q �(Jl Phone#:
Address: : 91_ Aj w q 15 1 S2 Q
City: i Uie'1 6 rt 5 State: FL
Tenant/Lessee Name: Phone#:
Email:
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CONTRACTOR:Company Name: ) O(,v Phone#:
Address:: �6 b F
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City: �� t G1�1 I � 1 `ate: F'jZip:
Qualifier Name: �( ?e/L-1 ¢_Q� �*► CJZ '� Phone#: 2
State Certification or Registration#: L-l� 13�I c�Ua Certificate of Competency#:
DESIGN ER:•Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work: c')
Type of Work: ❑ Add' ion ❑ Altera ion ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: &(,�J ! V\ 7� r av M
Specify color of color thru tile:
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Submittal Fee$' � � Permit Fee^ $ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
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Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
of F
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Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
' City 't ' < State Zip
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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 standardsof 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."
_3
Notice to Applicant: As a condition to the issuance o a building pp f g 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.
{ , o
U Signature /( Signature L��
OWNER or AGENT _ CONTRACTOR a f
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
tA_ a / , a M A
0(4 day of �� I 20 by 8�day of r I 20 17 by
( rc�v1 l
yvho is erson�lly known to NVQ"Irk Yl'C� who is personally known to
me or who has produced B(o5 3•S 3\•Co a•<o�o I•U as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
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NOTARY P,o �TSIq�///// NOTARY PU C:
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• ,�' Ep�• r 1 ! t
Sign:= Sign: �-a-
Print. • ,-,�G`� '.kPrint: a1'�
Seal: �i��99`vn0ughlstSa`e\c••�OQo� Seal YAN PRIETO
UB[lC,STASE�� MY COMMI ON#FF 214031
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EXPIRES:March 25,2019
Bonded Thru Notary Public Underwriters
***********************************G*t************************************************************************
APPROVED BY fir/ t+fX Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)