EL-17-420 (2) e �� T
Miami Shores Village -
FEB 16 2017
Building Department
BY:
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 -- _
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 !Q
BUILDING Master Permit No. 2> p*:;, t !!I—u
PERMIT APPLICATION Sub Permit No.
MBUILDING ®ELECTRIC ❑ ROOFING ❑ REVISION EXTENSION RENEWAL
❑PLUMBING ❑MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 23D /-)& /0/ 5-/
City: Miami Shores County: Miami Dade Zip: /3
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: �Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): M I Phone#:
Address:,,
City: �`71a�/i ��a'�4 State: Zip:
Tenant/Lessee Name: Phone#:
Email: /
CONTRACTOR:Company Name: GX/J� Z 573 Phone#:
i Address: mo--5:0 _--'oZ-�
City: �OA;111% State: /' Zip: 33/8'3
Qualifier Name: lt)a�;� Phone#:
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 6 • ' (/ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration �❑ New
❑ Repair/Replace El Demolition
Description of Work:
Specify color of color tt hru tile:
Submittal Fee$ �50 ► 1>Permit Fee$ ' 'OU _ CCF$ + O CO/CC$
Scanning Fee$ Radon Fee$ S DBPR$ y - Notary$ �—
Technology Fee$ • Training/Education Fee$ y Double Fee$ �—
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
r
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: 1 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.
t
"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 on estimated value exceeding$250, 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 o urs seven (7) days after the building permit is issued. in the absence of such posted notice, the
inspection will not be approv and a reinspection fee will be charged.
--y -
Signature Signature
OWNER or AGENT CONTRACTOR
The foring instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
�l 0 day of 20_ 1 ,by ` /day of --0 20 11 by
l�CltYIo � by 11.04 7114001;who is personally known to 06c-6A- V tif�Ph ,wh 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 PUBLIC: NOTARY PUBLIC:
p ZOE SALGUEIRO i
E SALGUEIRO �Pa� "e"'
Sign: = Sign: Notary
-State of FloridaCommission#FF 245464
Print: - G�'05 4 R 4 Print:
°- o .Expires Jun 30,2019 ���'''�° Bonded through National Notary Assn.
Seal: Bonded through National Notary Assn. Seal:
�7
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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