FW-13-2332<i>9\`''
(,0\
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
❑PLUMBING ❑ MECHANICAL
JOB ADDRESS:
City:
Miami Shores
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
❑ ROOFING
❑PUBLIC WORKS
County:
IVED
DEC 01 2016
BY:.
FBC 20N
Master Permit No.4 VN1 1� 3 a °
Sub Permit No:-�-W 0- /3 - Z332
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Folio/Parcel#: Is the Building
Occupancy Type: CZ Load:
Construction Type: Floo
Zip: 33 (3 8
y Designated: Yes
BFE:
OWNER: Name (Fee Simple Titleholder): FA ?ere._ U L CI- V.
Address: 70 � � �a L V/ B 2V 7
City: 1J �'i\) 1 State: V
Tenant/Lessee Name:
Email:
NO
FFE:
Phone#: J 1 3 33
CONTRACTOR: Company Name:
44h
-vie
Address: 212 l S w 3 (e-9 A ;?.► r.• o 0
City: 14 (a'1`'t ( F Zip: 33 / 2 1
Qualifier Name: 1.A., I S -f L1 RC I" ?< c.) _VD Phone#: 78C, Z 2-2-- /07 (
State Certification or Registration #: , S 1101 0 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address: City:
Value of Work for this Permit: $ (_-k CO Square/Linear Footage of Work: 1
Zip: 3 3 001
Phone#:
Phone#:
Phone#:
State: Zip:
State:
Type of Work: ❑ Addition ❑ Alteration E New
E Repair/Replace
Description of Work: r W 11 0 — 1 3 - -13 3 Z
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $
Scanning Fee $ Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ l •
(12 0
(Revised02/24/2014)
BondinEf Comp2ily'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 commencem .s ust be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signa ure
OWNER or AGENT
The foregoing instrument was acknowledged before me this
2t day of U'Ov ( ,20 l to ,by
P:›0 Iq M2E2 , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
***********
;,:*':^.I%:4; LUZ ANGELA DIAZ
MY COMMISSION # Ff977012
oFn EXPIRES March 30. 2020
uic*-. *
APPROVED BY
as
Signature
The foregoing instrument was acknowledged before me this
P 22 day of err , 20b
L)I S C iapeA-13-5) , who is personally known to
me or who has produced S.0 as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
y
'A—•J t."- -�-
:'';; LUZ ANGELA DIAZ._. I
' '' '? MY COMMISSION # FF977012
z?i EXPIRES March 30, 2020
140713 O153 FlmrdUNohrySnviCrr.drn
************************************************* **********
Plans Examiner
Zoning
Structural Review Clerk
(Revised02/24/2014)