REV-16-1995 r
Miami Shores Village j 18 2016
i
Building Department BY:
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 TR
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2ML4
BUILDING Master Permit No.
PERMIT APPLICATION sub Permit No. 9�
i
❑BUILDING ❑ ELECTRIC ❑ ROOFING `REVISION ❑ EXTENSION ❑RENEWAL
y"
UMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE.OF ❑CANCELLATION ❑ SHOP
p. CONTRACTOR DRAWINGS
JOB ADDRESS: � /_1f NER- 13t-ki �11/LP pi
City: Miami Shores
•� County: Miami Dade Zip: 331.30
Folio/Parcel#: U- ✓Z 0rPQO 4*M Is the Building Historically`Designated:Yes NO
Occupancy Ty W*3 dXad: Construction Type: Flood Zone: V BFE: h-06 FFE:
OWNER:Name(Fee Simple Titleholder): '�Jt V� �1 r�d� Phone#: q n, IO Ids3
Address: OuPo Ct WIR k-: ' A V
City: MX CA State: r Zip: '33 j 3`b
Tenant/Lessee Name:
Phone#:
Email: T� //��
CONTRACTOR:Company Name: R�. ��IAIVY bjV-Q COY`dYW)t6 S ND Phone#: �'Rt0' 2316' 1 ZS(o
Address: 4t6oC) sv5 35 JJ�-+
City: k-k C Ck a State:
Qualifier Name: Phone#: (
i State Certification or Registration#: ^TZ� 1Do(CI L, �_--C/ertificate of Competency#:
DESIGNER:Architect/Engineer: � '( 2i� �'�Cd\lTf� Phone# —A -4
Address: J�;S R-z N-r.—= !!�V Cc's j City: t-k jaw i State: cL zip:— 31-3
Value of Work for this Permit:$ Em Square/Linear Footage of Work:
Type of Work: ❑ Additio ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: I DJ'('(1 KD `�'U =Y1
i
Specify color of color thru tile:
•� t
Submittal Fee$ Permit Fee$ l S CCF$ CO/CC$
Scanning Fee$ OZ� Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
l
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ (U W
(Revised02/24/2014)
I.
e
{
h
Bonding Company's Name(if applicable)
Bonding Company's Address
City State ' Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
t
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..... I
I 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 YOUr 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 on estimated value exceeding$2500, the applicant must"
promise in good faith t t a copy of the notice of commencement'and construction lien law brochure will be delivered to the person
whose property is a to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first ins ecti ich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection wi n t b app oved and a reinspection fee will be charged.
Signatu Signature
OWNER or AGENT C N ACTOR
The fo oing in trument was acknowledged before me this The foregoing instrument was acknowledged before me this
A day of �v�� 20 k J by k 0 day of ` 20 16 by
�1fy Ark who is personally known to who is personally known to
me or has produced 1rr-� �(1 1`� �(� _ as me or who has p oduced L -��'• r as
identification and'who did take an oath. identification and who did take an oath.
NOTARY PU LIC: NOTY P B IC:
Sign. - Sign:
Print: IREZ Print: tM
{ {
MY COMMISSION ale FF935000
Seal: .11Seal: - MY COMMISSION 0 FF93WW
EXPIRES November 09,2019 Vis. EXPIRES November 09,2019
1407)39d•0+63 nWAPN"22=:LW_^ 140713960163 PW1d0rq., .QW 4
k ,
f
APPROVED BY Plans Examiner Zoning
{
Structural Review Clerk
I
(Revised02/24/2014)
{
' t
)