REV-17-2744Technology Fee $
ck\O\c
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
BUILDING
PERMIT APPLICATION
▪ BUILDING 0 ELECTRIC ROOFING
▪ PLUMBING 0 MECHANICAL 0PUBLIC WORKS
JOB ADDRESS:
eic: 2) 67-7
Master Permit No.
Sub Permit No.
IN REVISION 0 EXTENSION El RENEWAL
RECEIVED
NOV ? 7 2017
BY:
CHANGE OF
CONTRACTOR
City: Miami Shores County: Miami Dade
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load: Construction Type:pFlood Zone: / OWNER: Name (Fee Simple Titleholder): S r2 T o N
Address: 3 7 i Q% ( S 7`-
S F—L_
City: �( ai'+'Il � AO /LC � State:
St-h
FBC201'
91C It- 2356
kv 2:0/
Ei CANCELLATION 0 SHOP
DRAWINGS
3
NO
BFE: FFE:
Phone#: 3 D r - 4S -3 79l
Zip: 331 3 0
Tenant/Lessee Name: Phone#:
Email: Sail o/ O ///ti)/4-7 a e1. () 01-7
CONTRACTOR: Company Name: ALL a7-,vL71,-zacte coir Phone#: • - ? /9- 993 $
Address:
f2yo ow
City: t---1 (Ci.4'K a
State: f Zip: - j �/ E SQualifier Name: A it �(/ l Lti',C Phone#:
State Certification or Registration #: (` G C, 1 S Z- 27 ( / 7 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ r >oC0 Square/Linear Footage of Work:
Type of Work: ❑ Addition I i Alterati n n New
Description of Work: Ne. k) „ f !a. ( -
F1 Repair/Replace
n Demolition
Specify color of color thru tile:
Submittal Fee $ _ Permit Fee $ �S . CO CCF $ CO/CC $
Scanning Fee $ 4:1Radon Fee $ DBPR $ Notary $
Training/Education Fee $
Double Fee $
Structural Reviews $ - Ck Bond $
TOTAL FEE NOW DUE $ i G
(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, theapplicant 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 a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
�day of �f;jL ic�ii 20 , by �ay of pi/6ti,e, �r �ja,e , 20 ) , by
4
U .Gh who is personally to II knownA- r1 4\RDV\SO , who is personally known to
me or who has pr duced /"L 'v/zc t. P L ; Cvs.", as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
'',.;FoFc,.d:,'s Commis ion # FF 173169
Seal.
me or who has produced %= 2. b/u VQic L fC'S as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Sell:
****************************** **************************************sss********************************
APPROVED BY ! Plans Examiner Zoning
(
Structural Review Clerk
(Revised02/24/2014)