REV-18-535 Miami Shores Village
Building Department MA 8 1 1019
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 p
1 v S 1 2-2-
BUILDING Master Permit NoX4C—k-Q-k_=%
PERMIT APPLICATION sub Permit No.: /9 -
❑BUILDING ❑ ELECTRIC ❑ ROOFING dREVISION ❑ EXTENSION ❑RENEWAL
dPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 4-k0 u,R� -,�` etKz�
City: Miami Shores County: Miami Dade zip: �313g
Folio/Parcel#: \k3W GAO\-COO SQ Is the Building Historically Designated:Yes 'NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): Phone#:C—_,05)=-66(1 0--1
F
Address: +-1X0 U IF -z1 s''Ve&
City: SAX WAS State: Zip: M,31�
Tenant/Lessee Name: Phone#:
Email: \
CONTRACTOR:Company Name:\S'�f�Q CDpb�LECCIJ µp�Agnp�lp}ione#:Cacj�)�¢Q Sig 6
t Address:
City: _V,(_]S Qto c\p State: y\_ Zip:
Qualifier Name: Tlot�QLP;e V�� Phone#:
State Certification or Registration#: C �42-p1282 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ O Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace. ❑ Demolition
Description of Work: Q>rf fi t, N-,'�' W t APM.21 L
r ti 27'� � 141'c i t rrk. � ' ,•.
Specify color of color fffiui tiles .4�`~ r� ., 1
Submittal Fee$ Permit Fee$ �� 00 CCF ^:t ot�fai 3�ti CO CC
Scanning Fee$ o-4 Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond.$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
;
4
Bonding Company's Name(ifapplicable)
Bonding Company's Address i
City . -- AJI 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 a ction fee will be charged.
Signature Signature
OWNER or AGENT CONT ACTOR
The foregoing instrument was acknowledged before me this The foregoing' strument was acknowledged before me this
1q Cbl day of 74R ' 20 Va by day of c�'V—' 20 Va by
CMpVZ ,who is personally known to TWML� USA' who is personally known to
me or who has produced as me or who has produced Q\ as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC-7
Sign: _ Sign: .........
Print: Lel Print: '2 RI guez
Ricardo Dominguez PC ,tea
Seal: �� `� Commission +� FF958686 Seal: , Expires:Febrbary 8 2020
Expires:Fetuuary 8,2020 n�; Bonded#Ini Aaron Notary
Bonded thru Aaron Notary
APPROVED BY ✓ Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)