REV-17-1056BUILDING
PERMIT APPLICATION
❑ BUILDING
PLUMBING ❑ MECHANICAL
JOB ADDRESS:
City:
Folio/Parcel#:
Miami Shores
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
(21'CV Iv5� FBC 2014
Master Permit No. 6-C - !b - L /
Sub Permit No. PI%V l (dS L.
oilVREVISION ❑ EXTENSION ❑ RENEWAL
❑ ROOFING
AP 7 2017
❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
f f 5 Ao,b •- o) - a�7io
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):
Address: 7(210 ,f w)l
City:
Tenant/Lessee Name:
Email:
County:
Construction Type:
Miami Dade
Zip:
Is the Building Historically Designated: Yes
,54 Coil/
)3/q-
State:
Flood Zone:
BFE:
zr
❑ SHOP
DRAWINGS
NO.
FFE:
Phone#: %5'f/,E
Phone#:
Zip: W9.
CONTRACTOR: Company Name: ?II1SA6Z ��G I PRIG S-y r✓ Phone#:
Address: 162 5‘W PO
City: 1yo RTH
State: C-L
Qualifier Name: v).rb,L� .11xoti
Zip: 33-o& '
Phone#: -3Cq c5455-21
State Certification or Registration #: � - �7jOb (.01 �t Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:
Value of Work for this Permit: $
Type of Work: ❑ Addition, I— Alter ion
p r/i ',vl C
Descri tion of Work: r
,��dri (s rid
City: State: Zip:
Square/Linear Footage of Work:
❑ Neer 1❑ Repair/Replace ❑ Demolition
CUZHeS
Specify color of color-thru
Submittal Fee $ � Permit Fee $ 'mf� CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ ' Q
(Revised02/24/2014)
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 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) d• after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a r e will be charged.
Signature
The foregoing instrument was acknowledged before me this
v� �,,/� , 20 11 , by
,�.1 k A Oftni: -Jbt is personally known to
me or who has produced CL, t2-
identification and who did take an oath.
1 day of `AMA L
NOTARY PUBLIC:
Sign:
Print:
Seal:
APPROVED BY
as
�—ld
Signature
CONTRACTOR
1 t
The foregoing instrument was acknowledged before me this
Pc. day of rr l' , 20 �-R- , by
1 C �A kAl { M h ksOrAspersonally known to
me or who has produced .02 SO t "nI 3 -sc` - Kot ash
-iOl do
1) u2 Y\SC
identification and who did take an oath.
NOTARY PUBLIC:
Seal:
a
Z- 1 %d " / c1 Plans Examiner
MAHARAI K. GONZALEZ
, MY COMMIXION # GC 044602
EXPIRES: November2, 2020
Bonded Thu Notary Public Underwriters
Zoning
(Revised02/24/2014)
Structural Review
Clerk