WS-16-738 ,r
Miami Shores Village
Building Department MAS 92 2016
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Lo Tel:(305)795-2204 Fax: (305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2O
BUILDING Master Permit No. (,U `j —
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
'JOB ADDRESS: '10301f iN w ---140 A,�je U
!
City: Miami Shores County: Miami Dade Zip: 3311eQ
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): 4%n<�C I \ H Phone#: 05 `1:1),
Address: (U%C))A�f��/ "� i� rAyl/ _, •-� E
City: "I c16Y', `1'J tSl�e State: L ` Zip: Do
Tenant/Lessee Name: Phone#:
Email: �a p
CONTRACTOR:Company Name: I Phone#: �
Address: ti dJR-Z 1K� wC,( - f
City: l-1,o-z.Y State:_� Zip: � >
Qualifier Name: V �. �(. ��% S ` Phone#-7bA D7\ L-'J_T1
State Certification or Regist ation#: e___Gr1 i -27 Certificate of Competency#:
I
DESIGNER:Architect/Engineer: Phone#:
Address: _ City: State: Zip:
Value of Work for this Permit:$ y:t����� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New E� Repair/Replace f ❑ Demolition
Description,of.Work:
res+•ir,1!.i �1
il1�C I f ,...-, 04 '�_ �•3 . � ``t.+!' �_n:6'Z• �ii•t z5 tS�'.,r '�j/7'"'�`',• {�.
�d,JS i r jul ,J qY.`'..fS+"Ing�rti t w b'i v 5
t ,LF3
Specify�color.of color th_ru„ •;
Submittal Fee$ ' W Permit Fee$ '2-60 • Q CCF$ —t• og tiCO/CC$
Scanning Fee$17, (:3� Radon Fee$ DBPR$ 3 d 'Notary$
Technology Fee$ !C�l Training/Education Fee$ eL - 96 Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$,3 —7 W
(Revised02/24/2014)
f
Bonding Company's Name(if applicable) r
Bonding Company's Addfess
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. t„ , , J
"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 ORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimate value ex eding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien 1 brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of com enceme t m st be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is iss n he abse c of such posted notice, the
inspection will not be approved and a reinspection fee will be c
J
kv�\VC6 Si naturev`--' nature
Signature Signature
OWNER or AGENT CONTRACTO
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
�day of '�r.��r` 20k by day of'"—PVJYU 20ktb , by
ffl ')--NA-io o is personally known to V&L vdny� ��' ,wa is personally known to
me or who has produced as me or who has produced - I as
identification and who di a an oath. identification and who did to e n ath.
NOTARY PUBL NOTARY PUBLIC:
I �
Sign: Sign:
1 <r�"°�e o N DQ HERNANDEZ +
Print: „r. .,,' P < . 60 Print: s�--QI c�: «
-
�ro• * tary.Public-State of Florida Nr` :o, My Comm.Expires Jul 17,2016
Seal: Seal:
« •: My Comm.Expires Jul 17,2016 .',;FOF��o?�� Commission#EE 216934
%;F OFe�o�Qa Commission#EE 216934
......
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APPROVED BY r Plans Examiner Zoning
' � f
-1 Structural Review Clerk
(Revised02/24/2014) jI