REV-18-374Zip: 5� �4 j655
4
Phone#: 154•Z(4— (C95
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
95-2204 Fax: (305) 756-8972
BER: (305) 762-4949
BUILDING
PERMIT APPLICATION
BUILDING VELECTRIC ROOFING
PLUMBING MECHANICAL PUBLIC WORKS
JOB ADDRESS:
City:
•:CIA
REVISION
FBC 20 ( —_
Master Permit No.2- 18 220
Sub Permit No. �. JC,v 19-
EXTENSION El RENEWAL
CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
0C'S2 NE' I\*` CT.
Miami Shores County:
Miami Dade
Zip:
Folio/Parcel#: I I- Z 23 2— 0 Z j 0 5 0 Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Constructionl�Type:iFlood Zone:
OWNER: Name (Fee Simple Titleholder): m a1 �- I ` Y Qu i--
Address: V S 'e.ST ,?-\� • # 4 0 6city: �iO • �/ � iic �2
State: t L.
BFE: FFE:
Phone#: -I 5 4 50 5- 67 C'
Tenant/Lessee Name: Phone#:
Email: f co- C u a 0 a boo - r.
CONTRACTOR: Company Name: m ei 4- lc! h e• f Q leA-kg.I
C 2' Address: I ( �C 1
City: H (y V io k t StTe: i L Zip: �1 0 2 4-
Qualifier Name: �I eqf l�� 2 ` Phone#:
State Certification or Registration #: I— C i '3 Ci 3 9 7 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: ����-,�,,,,��,`.�� G� City: State: Zip:
Value of Work for this Permit: $ rg)- ++-L ry! 5/,500 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ olitio
r
Description of Work: ACA-C:I.I Q l412.1-'S r 6" a Vl sill 0 I62-5
and n+s -o ham- C)rr'* C s,
Specify color of color thru tile:
Submittal Fee $~:Permit Fee $ l lF� ��4 CCF $ 3 ' GO CO/CC $
Scanning Fee $ 3 • CA Radon Fee $ oc ' 00 DBPR $ 9 & Notary $ 5 • CO
Technology Fee $ . v O Training/Education Fee $ (• Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ o�/ q • ` v
(Revised02/24/2014)
Bonding Company's Name (if applicable)
pii.. c, 1 r-1 y
Bonding Company's Address¢ -•-
City - - :- -,t- � f State
Mortgage Lender's Name (if applicable) s""— ._ ._ rr.
Mortgage Lender's Address '
City --, _ i State Zip'
1
., ...Zip,, ..�:+r - f,.•M y
�r •,��•�. 11' :.. . e..
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.- , I
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
's} day of OYNCi ,20. ►C) ,by
MN C . N •Z , wlid is personally known to
me or who has produced , ,Y; V`Z If \ %c'. `nW as
identification and who didh.
NOTARY
Sign:
Print:
Seal:
************
NADY PRI
MY Ci MISSION # FF214031
EXPIRES: March 25, 2019
Bonded Thar Notary Public Underwdterr
CONTRACTOR
1
The foregoing instrument was acknowledged before me this
3 � Si —
day of `(Mai , 20 0, by
r/ •
)s personally known to
me or who has produced l ) rI Ve v \ IC,`e -9 as
identification and who did .. - .n oath.
NOTARY
Sign:
Print: , UtOn 0A-
J
r'1
Seal: _,.;+'?yam - YAN PRIETO
MY COMMIS ON # FF 214031
EXPIRES: March 25, 2019
.t`a'Bonded Thru Notary Public Underwriters
APPROVED BY / 7/L 40 -Plans Examiner
Zoning
Structural Review Clerk
3 e,
(RevisedO2/24/2014)