REV-16-2969Alteration
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
❑PLUMBING ❑ MECHANICAL
JOB ADDRESS:
4..2 °tic✓ 40 /
City: Miami Shores
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
FBC 20N//
Master Per iml t lib. / 20 c0 /
Sub Permit No.
REVISION E EXTENSION
❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
County: Miami Dade
Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load: Construction Type: Flood Zone: BFE:
OWNER: Name ee Simple Titleholder): y(4"-7 /
Address: ''" U ( 0 /
City: / ` ( .41' ' ( ‘S'-'60 State:
oate'- ' - lJ
❑RENEWAL
❑ SHOP
DRAWINGS
NO
FFE:
Phone#:
Tenant/Lessee Name: Phone#:
Zip: 2/ X O
Email:
CONTRACTOR: Company Name: com. z 4
t / 77/ 54.) e
Address:
City: /'1(
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Phon
6 vac-34/17/
State: v Zip:
CGC'/sfs 96
Phone#:
rtificate of Competency #:
Address: City:
Value of Work for this Permit: $ Sao
Type of Work: ❑ Addition
Description of Work:
L V` 5
Specify color of color thru tile:
Phone#:
State: Zip:
Square/Linear Footage of Work:
❑ New E1Repair/Replace
❑ Demolition
Zi 00JG S'6'62 FT‘
rli
Submittal Fee $ deg Permit Fee $WV 9
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/CC $
DBPR $
Notary $
Double Fee $
fl Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE$ I CC) Li •
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. Als• a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs.,seven )-days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approv �• - d . reins ' ection fee ill be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before ``me this
2g day of COC-*Z) ,20 lb ,by
/ �p ��who ispersonallyknown to
�j�
`P•gaf e.. r C:
me or who ha
roducecl
identification and who did take an oath.
NOTARY PUBLIC:
as
Sign:
Print:
Seal:
APPROVED BY
LT 4s
Zettie Jones
COMMISSION ! FF209081
PIRES: March 14, 2019
IIY4141Q
Signatu
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of 00G7 , 20 b , by
': v�1A' &i ,,,who ' personally kno o
me or who has producedp'as
identification and who did take an oath.
NOTARY PUBLIC:
c
ro, Zettie Jones
14Z'' 7,11 COMMISSION i FF209081
EXPIRES: March 14, 2019
M**************************s'!r ***WthaLuloialiet*R am***************
Sign:
Print:
Seal:
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review Clerk