REV-17-3001of �
Address: 3 `T /v
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC
PLUMBING ❑ MECHANICAL
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
RECEIVED
017
DEC 2 6 � C1%
Sfi
FBC 20P
Master Permit No. R_ 5-0-06
Sub Permit No. 1?-6\I 1 --)---S00'
REVISION ❑ EXTENSION ❑ RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 3 `7 / A) 5 9 O S
City: Miami Shores
1320(4204356 9._/
Folio/Parcel#:
County:
Miami Dade Zip: 33/3
Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): /7 E77 (ft /5✓I"{)i✓K{ Phone#:
E d/ 5 csT
City: "./9777/ 31VV/2eS
State:
Zip: 3 5/3
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: /c) / 3 �Z ) / Z - WU 7D
City: C /2/9L 6 //e/ A! 6 5 State: _ Zip: 5 .36-7 f-
4_46a/�9/rI�‘- Phone#: 95z/. / t - 7-3
Qualifier Name: ) /'/ L4/92 Phone#:
State Certification or Registration #: er(; U 5 `7`/U Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ /2. a7-1-4 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑l Repair/Replace ElDemolition
,Y Description of Work: D ' 7-060.D E! )00v AA— 7 1 k +- 7L0( / el-
Specify color of color thru tile:
Submittal Fee $-36 Permit Fee $ 5° -- CCF $ i • —C) CO/CC $
Scanning Fee $ -2 • Radon Fee $ - c'`% DBPRtt''$ 2 • � r Notary $ OD
Technology Fee $ ` , O Training/Education Fee $ O ' Double Fee $
Structural Reviews $ �P% T Bond $ 9
L9
TOTAL FEE NOW DUE $ rO� • 45
(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 wh" h occurs en (7) - • ys . fter the building permit is issued. In the absence of such posted notice, the
inspection will not be a' • ,. d a • ' eins s e' ,o ee ' I be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of DU, , 20 1 , by
P1(MUY PDOV4f, who is personally known to
tfas
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Signature
CTOR
The foregoing instru ent was acknowledged before me this
<�-97-. day of _Oc e 6 � 20 / 7 , by
�e6 T l 7 , who i ersonally known to
me or who has produced /v /4 as
identification and who did take an oath.
NOTARY PUBLIC:
Sig Sign:
Print: Print:
,q-1a 62-
Seal: foFF�� Bonded 7hru Notary Public Underwriters Seal: 4" ..* *•,e`/o E=IRRGANG
, MY COMMISSION # FF 970207
a` EXPIRES: April 7, 2020
APPROVED BY
ieOF FI.o Bonded 7hru Budget Notify Services
Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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