REV-18-723 _Q� RECEIWEC
Miami Shores Village
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N MAR 21 2(11
Building Department e
10050 N.E.2nd Avenue,Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-0949
BC 20 tCA
BUILDING Master Permit No. k--1 - 75
PERMIT APPLICATION Sub Permit No. ZE X , e
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BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOBADDRESS: 1430 17i;;� 102— SVL>Afi
City: Miami Shores County: Miami Dade Zip: 31���
Folio/Parcel#: t i _3�—O_,--O2�X—02?gyp Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name(Fee Simple Titleholder): i?�.X Phone#:C—CI
Address: 6-c70 ur 3l't2a�t-
City: LA W.h1 State: tL Zip: 3313
Tenant/Lessee Name: Phone#:
Email: IAG�O���►� dC�Mlac.CQt.I
CONTRACTOR:Company Name: V1�314QQ Q oG'k0k, Phone#:C� '—k sysc_sc.
i
Address: tkEaak
'City: State: 1__ Zip: 333ZS
Qualifier Name: tazzlAy !i Phone#:
State Certification or Registration#: 4Lr_C Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work fo'rthis'Permit:$ t 300 Square/Lineae Footage of.W_ork
Type of Work r"❑,Addition ,❑ Alteration= ❑ New ❑ Repair/Replace4❑ Demolition
Description of,Wo"' �`jJ�t4> l�S"C! - 1' "G Lll>5� '°1d`+c4t3�fi 'y
�sn�(_`r T�O+✓t �t��b c�uALl. �Q.cx-a.��=- ,
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$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE
(Revised02/24/2014)
k
Bonding Company's.Name(if applicable)
:1 \ G;
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 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.
"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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
4
Signature Signature_?/ OxdlL,
OWNER or AGENT ONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrum t was acknowledged before me this
`21 day of Ana1Cac A- 20 1$ by 2-1 day of (\nL�+ 120 l� by
16yb�cAO V\t_S�(�l3l�IPr ,who is personally known to y2QSLD\P'o V QD..& who is personally known to
me or who has produced as me or who has producedas
identification and who cid take an oath. identification and id take an oath.
NOTARY PUBLIC: `� �' �%' Ricardo Dominguez Rieft Domit�et
Commission # FF958686 NOTARY PUBL = Commission 0 FP968886
a ., Expires:February 8.2020 Expires:February 8,2020
Sign:
nded thru Aaron Notary. Sign: Bonded Vn Aaron Notary
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Print: Q\CAS Print: _X CAC ��
Seal: Seal:
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)