REV-17-2939BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
❑PLUMBING ❑ MECHANICAL
JOB ADDRESS:
City:
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
❑ ROOFING
❑PUBLIC WORKS
///6 Alf 2-gr
Miami Shores County:
Master Permit No.
Sub Permit No.
RECEIVED
DEC 1_I
42017
1/1
S1-)
FBC 20 l�
?P-- -/-._ 22-70
El/REVISION ❑ EXTENSION ❑ RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Miami Dade Zip:
Folio/Parcel#: /1— 3-2_0 S' '® a� —6 4 a 0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type:
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): v ((r, . ► reo- JIN Ru
Address: MG n 'c2 ST
City: W t1AO7LE. State: Zip: 33 I s-Q
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: N l}'ri (S Kul P001 D42..p Phone#: 303 - ? `70
Address:
`/�2i SL✓ i4L7 hive V%Irl- /Z.
City: (C& ✓-1
Qualifier Name:
State: r C---
f "l�rcc%a o c! ,iGl
State Certification or Registration.#: (7 U
DESIGNER: Architect/Engineer:
Address:
Phone#:
3�S -30306
Zip: 33/ 9 T
Phone#: 3 0 r F 70 — QFt"3
Certificate of Competency #:
Phone#:
City: State: Zip:
�1 1
Value of Work for this Permit: $ 00 - Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration n New
Description of Work:
Repair/Replace ❑ Demolition
'2) u nib; '�' ( / u rct-e. V a c t/U ni) Sier ry) en..2✓
i j p ✓ cu-t(Jvi
Specify color of color thru tile: c,,oz)
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
CCF $ CO/CC $
DBPR $ Notary $
Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE $ ef-` ' Q
(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, theapplicant 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
g" day of DeeeYrlae Y , 20 ) , by
Vi c, -o1'I o eI,9 rOln, who is personally known to
br i \Pe 1 1 i GQY1S1 as
me or who has produced
identification an who did take
Sign:
Print:
Seal:
YANAD •RI ; 0
'COMMIS' FF214031
EXPIRES: March 25, 2019
Bonded Thru Notary Public Underwriters
The foregoingfoinstrument was
ss-acknowledged before me this
1 \ day of�,�D� r1 rZ-�,..� , 20 (1 , by
a4-C-(=60 Iwl.n`"",`who is personally known to
me or who has produced tt=(" It' as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:\°
\5 'pN EXP/ *•
Print: zQ<y�'.ec,co 9o2r� 94 -: o �
EZ
Seal: _ `;c �v ' r =
i•FP ct�=
Z �S F9�1 �?� ri
ssrr**......*.*s*****sssss•sss..ss>Rsssssrssiss*ss*sssss*•*ss.f*s*ss.*r#*#•*t.s*ss*■►.. s4%•e44 less.
*A Ryp pow;
Plans Examiner Zoning
APPROVED BY
Structural Review
Clerk
i
(Revised02/24/2014)