PL-17-419 (2) Miami Shores Village CKTK
Building Department FEB 16 2017
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949 S
FBC 20 t
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.,--
❑BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION []RENEWAL
[PLUMBING ❑MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
NGS
CONTRACTOR
JOB ADDRESS: D
C unt : Miami Dade Zip:
City: Mia miiSShores (�
�// �� �� I �� Is the Building Historically Designated:Yes NO
Folio/Parcel#•
BFE: FFE:
Occupancy Type: Load: Construction Type: Flood Zone:
OWNER:Name(Fee Simple Titleholder): Q/� [yr� t ZQ SPS Phone#:
Address:
City:
Tenant/Lessee Name: Phone#:
k �
Email: �
CONTRACTOR:Company Name: / /plt;a� '"pP1 Z� Phone#:30s y1"' ,8I
f
Address: S '57Gl) 13Z aCe
Z;
City: �� /J State: p
Qualifier Name: (� /d v el-V Phone#:
State Certification or Registration#: l7� Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ ��' Square/linear Footage of Work:
i
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace [] Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee$ 531 Permit Fee$ oZ�S' CCF CO/CC S
Scanning Fee$ q t-� Radon Fee$ DBPR$ �_ �S Notary$
Technology Fee$ " Sy Training/Education Fee$ `O Double Fee$
Structural Reviews$
Bond$ "��
TOTAL FEE NOW DUE$ jZ .
a �
(Revised02/24/2014)
' 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.
"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,One delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commenC-e;r1,P4nt m6st be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In t absen a of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
i
Signatur - Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The fore ing instrument was acknowledged before me this
day of 20 1 by day of_ 120 ,12 by
(�J y�Gl7�7Ai✓�'Swho is personally known to )tom ��Ale," -,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.
NOTA 'may NOTARY PUBLIC:
y I. 10E SALGUEIRO]1da
I
�P�a��,4.- Miss-Ion
Sl(1LGUEIR0 ,`IPRVP&&%
*° (�� State of Flnri la Notary Public-State of
Sign: •' Sign: Commissl Boadedib my
C ip Zp I g %�� My Comm.Expires Jun 3Print• "' Print �� �.
Seal: Seal: t
s:ss****ssssss***sss*s•r*ss*rssss**s::ssrs*s*sssss*�.ss•**s****��sssssssss**sss**ss****■sssssssss****ss«s*ss
APPROVED BY ��o�I Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)