REV-18-1649 a '
Miami Shores Village
Building Department '1 �r5oi8
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
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INSPECTION LINE PHONE NUMBER:(305)762-4949
l FBC 20,iq
BUILDING Master Permit No. A
1
PERMIT APPLICATION Sub Permit No. _ — (0q C!
❑BUILDING 'ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
QCONTRACTOR DRAWINGS
f JOB ADDRESS: �� 5 /�e !9 S/ _i
City: Miami Shores County: Miami Dade Zip: ✓��/ o
`Folio/Parcel#: ti:s Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER:Name(Fee Simple Titleholder): JoS� (j d �/yW t� Phone#:
Address: 0 S.S AJe- 9 fl'
City: N1,4H1 SPOKeJ f7�—
State: Zip: 33/3,f
1 Tenant/Lessee Name: Phone#:
Email:
a CONTRACTOR:Company Name: 91 C0YT6&Ct V-6 6)V12_ Phone#-� .48 6 4
Address: K 10225 SW 1(� ��-'^^ {
City: ((,�, uL State:)( FL Zip:-t
-33 I qj
Qualifier Name:X anki l '0OG .eA Phone#: k rD q30 F:�C
State Certification or Registration#: X EC 13004 0 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address:_ City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work: 0
Type of Work: ❑ Addition ( ❑ Alteration ❑ New ❑ Repair/Replace E] Demolition
Description of Work: L lejl, /GX �Q Uf5iOV1 r f�C ,
All 11 -10,
f
J:h t=it 5 AIS ')O �fQ✓ �[ r •3 1 4.,
Specify colo of Folora ►r(J,tide: �. `` "A = 'Iff z i.o� .�(J,pp.�,�
1 " 1' �1 <errnrs_] ::. n..vn:n+^C'.) •il L +{• I.
OSQS.(.i,�2sv+.�4d3 » 4^E'M c4�Gam.,'. �OSO�.'r s2?y•i,��? 'i1�1'a Y'+f "•�'�.'""`�
Submittal Fee$ -,ie •,.�,"v=r�� •3. Permit Fee$ ' I <G'� CCF$ _•.�,=��CO/CC$,rv� .......''
$ 4g !r�°Wy a^Xs 7£e+ .�+ r�wc}. zc 1rT.�a : --'4'V xq�„'�SF�"^4W.`�,ct�r:.WF
ScanningFee Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education.Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 3 00
(Revised02/24/2014)
•i i+i 'f,moi
Bonding Company's Name(if applicable)
I ,,, t:1,.
Bondi ir&,o pany,s. :Address > _
City ( ,1 State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip `
Application is he eby 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. ' u
"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 abs ce o ch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
r
Signature X Signature
OWNER or AGENT CONT CTOR
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The foregoing instrument was acknowledged before me this The for instrument was acknowledgedFforeethis
day of JEV AN-, 20 by day of 20 Y by
jiv-so L✓UllOrtl1 — ,who is personally known toy{/L /?O b,�>�.J 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.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: - \v�I� '"!G -�../� Sign
Print. 6"Av), _0 Print: AQA .4W 76-0
Seal: A_ 0. ADA&PANDO Seal:' ;•", �""'•., ADA 8.PANDO
='+Q��r P�*`t+= Notary Public•State of Florida
�� '�� Notary Public•State of Florida
5 COmmISSIon N FF 993787 •_= Commission M FF 993787
My Comm.Expires Sep 14,2020 ��+, s My Comm.Expires Sep 14,2020
***** *��+w 's*+aoeMd(hndpA4Val�ett �; ******************* *s2i.9�"��s*6eadelthreU811NatiHWMefar�r
APPROVED BY /14_� )Q/p 10 Plans Examiner Zoning
n
f Structural Review Clerk
(Revised02/24/2014)