REV-17-841 FAV %Dl
,;K �` Miami Shores VillageIRF
4BY
zo17
Building Department
OL
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
�\ Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(30S)162-4949 S V)
1 FBC 2& 4
BUILDING Master Permit No. 1V l 1-1
' PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING M REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING [4MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION- ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:1-41
City: Miami Shoresyy,� �1 -�J County: Miami Dade Zip: �t/
Folio/Parcel#: 1 19101 y'�� • )NO Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Lo
Type: Flood Zone: BFE: FFE:
' OWNER:Na�m)eff(Fees (Si),m� le Titleholder): Lo �/� Phone#:
Address:
City: State: I L Zip:
Tenant/Lessee Name: Phone#:
Email: I
CONTRACTOR:Company Name: 7kPhone#: AD oil]
l] 1,
Address: '�` cl ' ST° _
yn
City: ,vl1 �J el''
� State: Zip:
533M -
�Qualifier Name: �J Phone#: VQ01
State Certification or Registration#: Certificate of Competency#:
4 t
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ a Square/Linear Footage of Work:
e
Type of Work: ❑ Addition on(� ❑� Alterations � �❑ rNew�#.� [:3.Repair/Repla ❑ Demoliti n
Description of Work: 10 1—�(7` ml
f.
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ 1yo CCF$ ' �0 CO/CC$
Scanning Fee$
Radon Fee$ ,F DBPR$ 2 Notary$
Q
Technology Fee$ • OO Training/Education Fee$ . 2 Double Fee$
t Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
F
F
t_
Bonding Company's Name(if applicable)
Bonding Company's Address _
City State ' Zip
Mortgage Lender's Name(if applicable) I
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.
k
i
"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 d livered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of compenjernent must posted at the job site
for the first inspection which occurs-seven (7) days after the building permit is issued. n th absence such posted notice, the
inspection will not be approved and a reinspectio fee will be charged.
Signature Signature
f OWNER or AGENT CONTRACTOR
The foregoing insti�umnentt was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 In by �� day.of 20 iq by
10eA UkKIDT who
11 is personally known to who is personally known'to
me or who has produced — QL as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
f '
Sig i Sign:
':JA Print l�
°�µ MY COMMISSION#FF035961'
Seal: �- CHRISTINAWILLIAMS Seal: 2`
Y. EXPIRES:AUG 12,2017
MY COMMISSION#FF035961 "pit 9ondsd through 1st State Insurance
EXPIRES:AUG 12,2017 ---
,,,.�'` Bond^d throu h 1st State Insurance
v V
APPROVED BY Plans xaminer Zoning
Structural Review Clerk
(Revised02/24/2014)
Y