REV-18-1392okk\
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BUILDING
PERMIT APPLICATION
BUILDING
PLUMBING
JOB ADDRESS:
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
❑ ELECTRIC ❑ ROOFING
❑ MECHANICAL ❑PUBLIC WORKS
(dGSheet-
M
FBC 20
Master Permit No. iC. l C — 2 ff g
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Res Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ewlovida- f"'t T e
Address: O /r (09 S/-
City: M%� cam) .4, Ores
Tenant/Lessee Name:
Email:
/J/A'
State: EL.
Phone#:
Phone#:
zip: 33/C 1
CONTRACTOR: Company Name:.S FL-, NWl
Address: ' QD Sj;cJ 5,6
City:
State: 1°(---
Qualifier Name: 11464 et4--inoki -5D
State Certification or Registration CGc.._/3/ Z<SJ
DESIGNER: Architect/Engineer:.
Phone#:
Zip_ 333 /Y
Phone#: of 11, 636-6ff)
Certificate of Competency #: A
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ WM-
Square/Linear Footage of Work:
Type of Work: ❑ Addition i I Alteration ®. New
Description of Work: ►" Q 19 ie S D v e r ,it w
❑ Repair/Replace
Ccc . s
Demolition
Specify color of color thru tile: •
Submittal Fee $ llj
Scanning Fee $47r, . co
Technology Fee $
Permit Fee $ �� , w CCF $ CO/CC $
'Radon Fee $ DBPR $ Notary $
Training/Education Fee $
Structural Reviews $
Double Fee $
Bond $ c /
TOTAL FEE NOW DUE $ I�
(Revised02/24/2014)
{ 4 i
Bonding Company's Name (if applicable)
Bonding Company's Address
44!
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip_
j ^.ta ,+
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
a
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. } 1
"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." , I ; ►
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.
Signature
t
OWNER or AGENT
The foregoing • instrument was acknowledged before me this
day , 20 1. , by
(q Yuti i5c,4-„,1, who is personally known to
rt
me or who has produced `Drt M'c k..10C Se as
identificatio . • who di
NOTARY PU
Sign:
Print:
Seal:
************.
YANADY PRIETO
s MY COMMISSION # FF 214031
a•,�;,= EXPIRES: March 25, 2019
*'y*. t•fe* entar at • . aidiaiepK+6e�*
The foregoing instrument \
ZZ day of
.fORSe• M:c
me or who has produced
identificati
NOT 'YP
Sign:
Print:
Seal:
APPROVED BY ���1� Plans Examiner
Structural Review
r 3 �
as acknowledged before me this
,20' 1 ,by
ho is personally known to
D t V'Q,r I ZNA.S‘.r as
LAW
YANAD PRIETO
MY COMMISSION # FF 214031
EXPIRES: March 25; 2019
kited hru Pubic undermitao
S/36 /`P`.
Zoning
— • Clerk
(Revised02/24/2014)
1