MC-17-2427Miami 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
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
❑ PLUMBING ❑ MECHANICAL PUBLIC WORKS
JOB ADDRESS: /2 6� N /o /
City: Miami Shores
Folio/Parcel#:
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):
Construction Type: Flood Zone:
e ®G/d4U /2r) mot)
Address: / 2 6 3 API' /p
City: /2/' G qi Sz o r€ s State:
RECEIVED
OCT 11 fir
S-h
2 C 2-I0�1y
Master Permit No._ l 1 --— 2L12,(0
Sub Permit No. M C Zy Z.1
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
S-¢..P4 -f pp�
County: a had Zip: 3 3l 3 5
Is the Build(f4 ric yi.: : nated: Yes NO
BFE: FFE:
Phone#:
3o2 /6 —22Zy
% *4 Zip: ? 3 /1 S
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: / / 1.� '4/ //'
City: j lfa 2ti
Qualifier Name: '14i{F1/1)
i
/P - re
State: i tE L `E D
trr
Phone#: "brig?fc-d z5:?
Phone#:
Zip:
90-2qo42r?
State Certification or Registration #: C45/C / 8/ ? 9P y Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ lL\ DOD Square/Linear Footage of Work:
Type of Work: ❑ Additio n Alteration New fi Repair/Replace ❑ Demolition
Description of Work: , /�L---2-2 ,17
—rp ( P 10CQ i'ic, 13- 3RU
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 90 CCF $ CO/CC $
Scanning Fee $ Radon Fee $ - 6 DBPR $ • 35 Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ J 3C2.. _ �S
(Revised02/24/2014)
t
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 tho i s unnro of n hnilrlinn norm7t with t + d ,'Ni".? exceeding c250"the ... Jlc. nt must
4 promise in good faith that a copy of the notice of co ent and construction lien law brochure will be delivered to the person
tp
whose property is subject to attachment. Also,a certi o�''
vf"x'bflhe recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days afterfh'e'bu►i 7 g,permit is issued. In the absence of such posted notice, the
inspection will not be approved� . l� p and a reinspection fee will be charged. .
c �' t., 1,
Signature
OWNER or AGENT
The foregoing(reinstrument was acknowledged before me this
(i day of
J' �I� V \ , l �20 t , by
ClOkbtJ VOl!/1 )frsonally known to
me or who has produced
I CO
as
identification and who did take an oath.
NOTARY PUB
IC:
1111011
Sig
Print:
Seal:
*********************
APPROVED BY
Signature eoin
CONTRACTOR
The foregoing instrument was acknowledged before me this
/�� day of 6- c�?U'+CY'— , 20 (� , by
^
l _ T'4t4t2-A• �r\"7 _& who is personally known to
me or who has produced L- bR! \-p (kc as
ideati if cation and who did take an oath.
NOTARY PUBLIC:
MAHARAI K. GONZALEZ
MY COMMISSION # GG 044602
0
Bonded Thru Notary Public Underwriters
1 0 PI ns Exa
n:
nt:
Seal:
} ra r'ot Notary Public State of Florida
-w Sindia Alvarez {
?� 'y My Commission FF 156750
os aplExpires 09/03/2018
Zoning
Structural Review
(Revised02/24/2014)
Clerk