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RECEIV�D
Miami Shores Village OR 09 1018
Building Department
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10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 Sh
FBC 201
BUILDING LL Master Permit No. CC -!Z - j 3®/3
PERMIT APPLICATION Sub Permit No. q ZO
I.❑BUILDING ❑ ELECTRIC ❑ ROOFING VISION ❑ EXTENSION ❑RENEWAL r
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR/J DRAWINGS
JOB ADDRESS: //300 �Y�, Z `1 ���� � �►t hy1-4 Qe,04 r
City: Miami Shores County: Miami Dade zip: :33/41
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Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: /Construction Type: Flood Zone: BFE: CFFFEE:
OWNER:Name(Fee Simple Titleholder): / �t�t ��.'Ve✓S�+ Phone#: 30 S —
Address: 1/300 IYJE. 2,nr/ �' r
City: ml-44,—w State:
Tenant/Lessee Name: / Phone#:
-Email: I j YAa /c t�/� s cw f
CONTRACTOR:Company Name: Skaev sj<-:� Phone#: �
Address: 13 0 Slit/ S fret" S✓. /
City:_ /�r'7- Zz.✓je,�, -e ) State:_ / W.'jZc Zip:
QualifienName:_ (4r'•°s tok`�/� re. /e/4 Phone#: y07- (-1614 '2//S
State Certification or Registration#: -f // Certificate of Competency#:
DESIGNER:Architect/Engineer: h'Arya, 4 JO/!Y Phone#: 571—
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Address: "2Q%? R/ih6eA4iate:
4/ova�Zip: 33L/11Value of Work for this Permit:$ '`-/^� Square/Linear Footage of Work: Sok-
Type of Work: ❑,Addition E3Alter tion ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: ! I^ ( "` i 4t
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ �d' �7 CCF$ CO/CC$
Scanning Fee.$ g (O, (3z) Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
' V �L' • ��• I ��' TOTAL FEE NOW DUE$ r �xJ
(Revised02/24/2014) o[d 450
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FR-(IS � � sl ��
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r 'oBonding Company's Name(if applicable) {
'Bonding Company's Address
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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
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 Signatur
OWNER or AGENT CONTRACTOR
The for ng instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 17 by �k day of �e a±GM6e-r' 20 0 by
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ADA who is personally kn�o C-h1,-1AopHC.7 who is personally known to
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.
NOTARY P LIC: NOTARY PUBLIC: `
Sign. Sign:
Print: Print: ��r b,{,i
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PENNY S
Lvv-�
otary Public State o1 Florida N
Seal: effry Yao Sea►: Notary Public•State of Floriday Commission FF 188481 Commission N GG 029905xpires 11/1212018My Comm.Expires Sep 9,2019, nor
I APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Rev1sed02/24/2014)
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