FW-12-1464Miami Shores Village if TMEWMT;
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A'JS 0 3 2812
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
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PERMIT APPLICATION
Maste
FBC 2010
No.V I -- V--(Oq-
Permit Type: BUILDING ROOFING
JOB ADDRESS: 185 N ( 7 ! S ( Og.City: Miami Shores County: Miami Dade2, 33 /.XJ
Folio/Parcel#: , ,
Is the Building Historically Designated: Yes' NO V Flood Zone: 41"
OWNER: Name (Fee Simple Titleholder): / i7/ Hee—DR/C/ Phone#:
Address: y4-.? y��ilt'S 5
City: // /// ( SX/W,eS State: / Zip: Y3j3f
Tenant/Lessee Name: Phone#:
Email:
�j/ �-/! !,!/'7 / �-C/L)J7��(/ em!(/ Phone#:.00? €72 -7—(J PZR?
Address: YQO / if0 SZt) 02V i -
CONTRACTOR: Company Name:
City: 7M/19717 / State: Zip:
S..S�
Qualifier Nam//e: �-tJSn 414? Phone#: 7U 6 02 > .777)
State Certification or Registration #: C -O.. O6-5- Certificate..of Cornb t cy #:
Contact Phone#: SC a vim-7 0 Email Address: IN/i VP
DESIGNER: Architect/Engineer: P one#:
Value of Work for this Permit: $ / i,�V Square/Linear Footage of Work: __�� !
Type of Work: •.OAdditionppjj�� , • °Alteration 'L ew 0— — "
Description of Work: bV 0, S tr/(Orr (A1 l / ( (
Color thru tile:
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***************************************Fees********************************************
Submittal Fee $ Permit Fee $ /oo
ad t CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE$ C • 9,0
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City b 'State Zip
Application is hereby made to, n,a'pennit to do the work and installations as indicated. ° I certify that no work or installation has
commenced prior to the issuance 6f 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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDmONERS, ETC
F
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 construcon 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 a ence of such posted notice, the
inspection will not be roved and a reinspection fee will be charged.
Signature Signature
Ownei or Agent
The foregoingoi/instrument was acknowledged before �e�'th_is
day of , (/6 , 20 /a, by 7M ,C�liGl'iz i
who is personally known to me or who has produced
As identific
NOTARY PUBLIC:
Sign: 6
Print: TQf C iD
My Commission Expires: 5--1 a— oW i co
sT
The foregoing ins
, day of % G , 20 /dr2, by T SE ,
wiMMi4dJta CA81 th.
NOTARY PUBLIC
STATE OF FLORIDA
Comm# EE198021
Expires 5/13/2016
Contractor
ment was acknowledged before me this .
who is personally, known to me or who has produced
as identification and who did take an oath.
•06gd
NOTARY PUBLIC: G
Sign:
Print.
NOTARY PUBLIC
TE OF FLORIDA
m# EE198021
s 5/13/2016
My Commission Expires: 5--i3 2i /fr
**************************************************************************
APPROVED BY
Plans Examiner
Structural Review
*********************************
YN/d
Zoning
Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
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PERMIT # ZO 12T 404-
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CONTRACTOR: COAWki Cf2M4(0a0311
SUBMITTAL DATE: bl
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ADDRESS: -
NAME:
RESUBMITAL DATES:
PROJECTTYPE: 1-eAACC
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STRUCTURAL
IMPACT FEES
ELECTRICAL
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PLUMBING
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