REV-18-1295r
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
PLUMBING ❑ MECHANICAL
JOB ADDRESS:
City:
Folio/Parcel#:
Occupancy Type:
I OC)(82
Miami Shores
II-2252
Load:
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
Master Permit No. P1 C--- I i& 1-0
Sub Permit No. V (V J (2._e 6
❑ ROOFING 'REVISION ❑ EXTENSION ❑ RENEWAL
PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
UE ti CT -
County:
O2$— 0500
Is the
Miami Dade
Zip:
Building Historically Designated: Yes
Construction Type: Flood Zone:
OWNER: Name (FeejSimple Titleholder : t' ahL 1_( ( �i
1 2
Address: -I 14- \fve • /v - Ct0'S
City: 14V [ fl )/ V I ` 1 a,p
State: 1 1=
BFE:
❑ SHOP
DRAWINGS
3�1�8
NO X
FFE:
Phone#: �- SOS' 6766
Zip: tY3
Tenant/Lessee Name: Phone#:
YNrC9c!a 6) yahoo. r'
Email:
CONTRACTOR: Company Name: Chcirn bPY (R s} ru Ct1 c ') Lc�.
Addres • t 21 ov v
, S
City: VeilnbrOke j(12S State: P-L
Qualifier Name: Car Ir \ aZkW
DESIGNER: Architect/Engineer: . �'" V V
Address: tc4-9q ME 19' tfrl Able . `# 20 a
Value of Work for this Permit: $ (5 Z1
Phone#: 9 51-- ' 610 - 5325.
Zip: `Yz202 5
Phone#: 1 6 - 5 41 "MSZ6
State Certification or Registration #: C G 6 5 6 5 4tificate of Competenc
y�(� nPh # �-6— 5 ---0 4- 6City: I .Ar( ). {t WI &k\ State: FL Zip: '3'3 I ‘Z
.-
Square/Linear Footage of Work:
Type of Work: ❑ Addition1Alteration 110 New ❑ Repair/Replace 0 Demolition
Description of Work: Ada InSuta-kr ki {tIr tTZh(Vtckri W' ( 1•
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $
Scanning Fee $ Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 1 I "l • ---
CO/CC $
Notary $
coo
(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
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 and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
f 5 ay of rn , 20 ( �) , by
r4Vc_ 1 , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
****************
APPROVED BY
*
*
A-91
*************************
7
Stephen Hidekel
NOTARY PUBLIC
STATE OF FLORIDA
Conant# FF947126
as
Sign:
Print:
Seal:
Signature
-)Z)M— C)—\
CONTRACTOR
The foregoing instrument was acknowledged before me this
(5 day�,f ,201 6 by
, who is personally known to
me or who has produced as
identification and who did take an oath.
ge //NOTARY PUBLIC:
A Aga Lai.`
fratfiNIff
Plans Examiner
11*
Stephen Hidekel
NOTARY PUBLIC
STATE OF FLORIDA
Comm# FF947126
ite#P°I***************
Zoning
(Revised02/24/2014)
Structural Review
Clerk