RF-17-1913 (2)Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION UNE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
(BUILDING ❑ ELECTRIC ((;ROOFING
['PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
ONTRACTOR DRAWINGS
JOB ADDRESS:
Master Permit No.
Sub Permit No.
RECEIVED
JUL 2 6 2017
et+4'/
FBC iolu
‘q-191.3
,/2 uJ 96 S
Value of Work for this Permit: $ T 0 0
Type of Work: ❑ Addition ❑ Alteration
Description of Work:
r
0 REVISION 0 EXTENSION D RENEWAL
City: Miami Shores
i- Folio/Parcel#: 11- 3101- 0
Occupancy Type: Load:
County:
0
Miami Dade Zio:
Is the Building Historically Designated: Yes NO
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): O C Gi C O Ir J� 4 Phone#:
Address: 6 ? -S _ 14°, v6ov D rs / City: taey Ai Seat , P State: F !/
up: `3 3 7Y1
Tenant/Lessek Name: /
Phone#:
Email:
CONTRACTOR: Company Name: 4,--, *e ,/ 1 h1061-fiti Phone#saa25-30-i-OSL,/
Address: 'g y:-on .5 7 5 p
City: �i State: _11,T Zip:‘..5,5JS'5
Qualifier Name:etx1a/ .5 e Se01,L.)OSG� Phone#f — 8/6%?t
State Certification or Registration #: a (00 /33D5 4S Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: _ ) City: State: Zip:
Square/Unear Footage of Work: 7-/ 6 9.
52
❑ New ❑Repair/Replace
,,//
ra
•�0 tie �i s ��G,4,r S
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 3 P C-io CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $3 .
TOTAL FEE NOW DUE $icl'P• ` 0
❑ Demolition
(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: 1 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.
• 4
Signature /sue 1 r
OWNER or AGENT
The foregoing instrument was acknowledged before me this
ff by
Ca(
t 4w at , who is personally now'I� to
me or who has produced as
Identification and who did take an oath.
NOTARY PUBUC:
rr
(t day of ( , 20 (
r
Sign:
Print:
Seal:
OSTA
COMt I55iuri A� GG000692
EXPIRES June 09, 2020
FloridallotaryService cam
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this /
t 7" - day of Fr
,20 (7 ,by
PLA&- v/5' C 5-0/ 40S
me or who has produced
identification and who did take an oath.
NOTARY PUBUC:
, who is personally now o
Sign:
Print:
Seal:
as
_t MY COMMISSION # GG000692
EXPIRES June 09, 2020
(407) 390-0153 FloridallotaryService.com
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APPROVED BY Plans Examiner Zoning
Structural Review
(RevIsed02/24/2014)
Clerk