REV-16-2631BUILDING
PERMIT APPLICATION
[01
BUILDING ❑ ELECTRIC
[PLUMBING ❑ MECHANICAL
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
5
FBC 2014
Master Permit No. WS-2154
Sub Permit
No. PNEY I Q 2(o3 1
❑ ROOFING 0 REVISION ❑ EXTENSION ❑RENEWAL
❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR
JOB ADDRESS: 9950 NE Fourth Avenue Road
DRAWINGS
City: Miami Shores County:
Folio/Parcel#:
Occupancy Type: Load: Construction Type:
Miami Dade Zip:
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple Titleholder):Amanda M. McGovern
Address:9950 NE Fourth Avenue Road
City: Miami Shores
Tenant/Lessee Name:
NO X
Flood Zone: BFE: FFE:
Phoned: 305-582-4244
State: FL Zip: 33138
Email: amcgovern@riveromestre.com
CONTRACTOR: Company Name: /` C bid .t/ 12
Address:
City:
Qualifier Name:
State Certification or Registration #:
Phone#l:
t-)4
State: Zip:
Phone##:
Certificate of Competency #:
Phone#: 305 754 02318
DESIGNER: Architect/Engineer: Mark Campbell
Address:373 NE 2nd Avenue City: Miami Shores State: FL Zip: 33138
Value of Work for this Permit: $
Type of Work: U Addition ❑ Alteration
Description of Work: //✓ir
was Sp✓A2c p f
Specify color of color thru tile:
Square/Linear Footage of Work:
n New ❑ Repair/Replace ❑Demolition /
,4•ta •
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $, CO/CC $
DBPR $ Notary $
�._. Double Fee $
Bond $
TOTAL FEE NOW DUE $ .........._ .
4Revised02/24/20 4)
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 coction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the reco . jto 'ce of commencement must be posted at the job site
for the first inspe .n which occurs seven (7) days after the building per ed. In the absence of such posted notice, the
inspection will no be ... proved anreinspection fee will be charged.
eee40
Signature
Signature
OWNS' or :`GENT CONTRACTOR
The foregoing strument was acknowledged before me this The foregoing instrument was acknowledged before me this
22 day of September , 20 16 by day of 20 , by
, who is personally know» to , who is personally known to
as me or who has produced as
Amanda McGovern
me or who has produced
identification and who did take an oath, identification and who did take an oath.
NOTARY PUBLIC:
Seal:
Imo.
`:'► Y 1,, NICOLE a. RUIZ
Notary Public - State of Florida
Commission # FF 165195
Bonded through National Notary Assn
APP
s AI& 411,A111, `_
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NOTARY PUBLIC:
Sign:
Print:
Seal:
Plans Examiner
Zoning
IRevised02/24/2014)
Structural Review
Clerk