PL-17-2433r
0
DESIGNER: Architect/Engineer:
Address: City:
Value of Work for t Permit: $
Type of Work: Add' ' ❑ Alteration
Description of Work: 6 G. I
3 a0c>.
JOB ADDRESS: tap ick.%
City: Miami Shores
Folio/Parcel#:
BUILDING
PERMIT APPLICATION
❑B ILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
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
RECEIVED
QKT112017
FRr ?n\ -4
Master Permit No. eV-C. 19
Sub Permit No. PA ` 3
f v 1
County: Miami Da
r NO.
Is the Buildi _ Storroa5Le
w.o 1
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):_
Address: 1 2 (.3 , A ..+' (✓
City:
Construction Type: 4J
cOts
Flood Zone:
CI -kJ 01 _DD6(-1 6U�
IL .S e
Zip:
Yes
BFE:
RENEWAL
❑ SHOP
DRAWINGS
33/3F
NO
FFE:
Phone#: 305 — 2 / fo - Z 2 ? -
t 6 r A-t- i S-17O e S State: C Zip: 33 I (�
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: •. --, i.IUNAg ( cO 1 Phone#:
Address: KM?. / 1-(A) 3 2 C
City: 7 "- Ate: VI ,
ED
Qualifier Name:
State Certification or Registration #: C(PC l9 Z i is 0 3 Certte$of Competency #:
Phone#:
State: Zip:
Square/Linear Fopfage of Work:
Repair/Replace n Demolition
OS+✓ —7DI ii ko lo-
SS-9a -7)Wo
Zip: 34)/ U
30S—q G—8,�
ctC/4.z63g7
❑ New
Phone#:
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ S ,-,V * O
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $
DBPR $
CO/CC $
Notary $ 5 c
Double Fee $
Bond $
TOTAL FEE NOW DUE$ � - OS
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's.Addr'ess
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 betdone„incompliane 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 ofa building' a,. ` ed '1i pp permit with 6n 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 . -'.s.ection fee will be charged.
G.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
c_lo.. day of
r
Signature ..
CONTRACTOR'
The foregg instrument was acknowledged before me this
Zof
, 20 1-9' , by: Y Z'B' day of S-EcTcM5 _-, 20 , by
GCA) 41 0 Pew Igfaj Sbnally known to m - V' � vP , who is personally known to
me or who has produced t as
identification and who did take an oath.
NOTARY PUBLIC:
Sign
Print:
Seal:
APPROVED BY
'*s� EXPIRES: November 2, 2
=" : g.ose BondedPublic Underwriters
o Thn+Notary
fr(ib
me or who has produced ag-k, vT «a- CC--' as
identification and who did take an oath.
NOTARY PUS IC:
Sign: Si
Print: S 1 t t A
Seal:
�"V Y1"V
nGeeNrSel "fY'1+Y Ylr`Y"1r •V r
oJAY "gee Notary Public State of Florida
? ? Sindia Alvarez
ea My Commission FF 156750
Jr *or 004. Expires 0910312018
Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)