REV-16-2774 i
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RECEIVED
' Miami Shores Village OCT 13 2016
Building Department
10050 N.E.2nd Avenue,Miami Shores, Florida 33138
i Tel:'(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
' FBC20fy
BUILDING Master Permit No. CC- -12. - (S 300
PERMIT APPLICATION Sub Permit No.
❑BUILDING �Q ELECTRIC Q ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING F-1 MECHANICAL F-1 PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: // 300 f L
1?4vD FiNC
City: Miami Shores County: Miami Dade Zip•.
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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): 6AUy 0,A) 1(L-4zjl t5� Phone#:
Address: 13 /��` 0 �1! • , MIAMI �t/U/Lg AC -33)61
City: -- State: Zip:
77
Tenant/Lessee Name: e/�FFOeY YAO Phone#:
Email: TMA 00 .4A80--y . CbV
CONTRACTOR:Company Name: ►t(�� v I`� �e Phone#:
(.9 (57( �¢
Address: l �t� �:
City: �Ak _ State:_
9'1.,- Zip:
Qualifier Name: Phone#:
State Certification or Registration#: (:.IC J� Q� / Certificate of Competency#: C
DESIGNER:Architecct/Engineer: C.. - Phone#: 561 V 7-8 yyJ 7Z'
Address: Z 7 - ' Vl S A U 700 City: CST 6 tate:�Zip: 3 3 y l
Value of Work for this Permit:$ . O - O O Square/Linear Footage of Work: 4 S
Type of Work: ❑ Addition Lam} Alteration ❑ New ❑ lace Re air Re
!!! P /� P ❑ Demolition
Description of Work: G7t✓/M//V,4T/ 0& DE: //C_A/ 6b—=�11/ %ALi�AN El,
�Xlsriiv G Ab LL- 6C US'�� ti � c .D
L1 ' �)6 khAl &uz 6N
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ rs CCF$ CO/CC$ w
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
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StructuralReviews$ Bond$
• TOTAL FEE NOW DUE$
(Revised02/24/2014)
F
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�y
+ Binding Company's Name(if applicable)
P,
Bonding Company's Address t
r City State Zi t
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Mortgage Lender's Name(if applicable) •
Mortgage Lender's Address
City 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 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..... {
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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
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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.
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Signature Signature
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OWNER or AGENT CONTRACTOR
The foregoing inst"rum was cknowled ed before me this The foregoing instrument was acknowledged before me this
day ofs 20 �CO . by day of 20 1 by
ho is personally known to c who is ersonally know to
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1 me or who has produced 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 PUBLIC: 001111111111q// NOTARY PUBLIC:
\��� IRIS
S ;•�y PPn1?e,�••: Sign:
Print: Print:
- / g r ✓ s,.�. �,�, 0• m• _ �6
Seal: s cgs 033j wY eye, DONETfE .VILLEGAS
-g-.•,o Seal:
nth, ., MY COMMISSION M FF 181029
�i l%••• rvrtltecs• •'Q ��� EXPIRES:December 4,2018
��//C S '••••'' Q��\\� }pt F°:' Bonded Thru Notary PubFc Underwriters
APPROVED BY �/� i l9'�l'l�i Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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