REV-17-1055BUILDING
PERMIT APPLICATION
XBUILDING ❑ ELECTRIC
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
t REVISION
❑PLUMBING ❑ MECHANICAL El PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS:
City:
Folio/Parcel#:
Occupancy Type: Load: Construction Type
13g
Miami Shores County:
11- 3h -013 -a77io
Master Permit No.
Sub Permit No.
❑ EXTENSION
FBC 20\4-
s+
P ev I—l—I055
❑ CANCELLATION
Miami Dade Zip:
❑ RENEWAL
❑ SHOP
DRAWINGS
Is the Building Historically Designated: Yes NO . x'
OWNER: Name (Fee Simple Titl holder).V/`;
Address: .7210 ,v, Gvt
City: —ralG1
4-131`
State: F
Flood Zone: BFE: FFE:
bud
Phone#: qfI 5' `3
Zip: 33,6/ 4
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: / v P\-ECQi
Address: J r (G-4-
vA I ,
Qualifier Name: vV k 1
City: M (..A� / �C
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Address:
Stat
Phone#: `'V J r 762
Zip:
Phone#:
'f- 7 , Certificate of Competency #:
Phone#:
City: State:
Square/Linear Footage of Work:
Value of Work for this Permit: $ Alguk,
Type of Work: ❑ Additiop, n Alteration
Descr ption of Workc -
lqr I ,:^; r�n/I'� ,. .i?a,,, -
�• RAM i r'
Zip:
Repair/Replace n Demolition
I/i
Specify color of color thru tiler
Submittal Fee $ Permit Fee $ �� �� CCF $ CO/CC $
Scanning Fee $ (55' O Radon Fee $ DBPR $ Notary $ S•O
Technology Fee $ Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE $ 2-I v . Lcs
Structural Reviews $ ( '
(Revised02/24/2014)
Bonding Company's Name (if applicable) -? i
ii�
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City k State _ Zip
`+ 1'
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 tierrnit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC....'
OWNER'S AFFIDAVIT: l certify that all the foregoing informatio:i is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
i5
{
"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 bu'Iding permit is issued. In the absence of such posted notice, the
inspection will not be approved and a r-ction fee will be charged.
Signature
OWN R or AGENT
The foregoing instrtimenfwas acknowledged before me this
/ �1, - day of
/k?2.i L , 20 rr , by
(11 0-' o is personally known to
me or who has produced Imo' U (. _ as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
APPROVED BY
(Revised02/24/2014)
Signatur
The fo
re
�going instrument was acknowledged before me this
1 day of -NPr I ,20 I-9" ,by
an 1 b-ex6 -P Qd.‘F% is personally known to
me or who has produced --0 3(00 ,S-G Zas ~ o
identification and who did take an oath.-IOr K% : CCA-1
20e7 I Plans Examiner
...,
�: MY COMMISSION # GG 044602
EXPIRES: November 2, 2020
Bonded Thru Notary Public Underwriters
Zoning
Structural Review Clerk