REV-16-2015BUILDING
PERMIT APPLICATION
BUILDING ❑ 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
FBC 20 (LI-44
4
Master Permit No. 1C-6 - /.5 -(�rAll6j.2 y
Sub Permit No. 'Et jj �J -20 ! 5
❑ ROOFING Jam' REVISION
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF
` (� ?//t� . ;� CONTRACTOR
JOB ADDRESS: f 2-� I /J �S 4 t t RUC I
City:
Miami Shores County:
Folio/Parcel#: 113 2
OSo !boo l0
Miami Dade
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
Zip:
Is the Building Historically Designated: Yes
Occupancy Type: Load: ‘DU
17.cC�onstruction Type: Flood Zone:
OWNER: Name (Fee Simple
ldTitleholder): DUAR D L- 0 -S.
1
Address: l2U 1 `` I1OIvt 7. T4 cr ��
�� City: 1 (\ ( "OS State:
Tenant/Lessee Name:
Email:
AV-14
BFE:
Phone#:
NO
FFE:
6 --5(Z -'97)l
Zip: 3 3 ( )`e?
Phone#: 1//4
CONTRACTOR: Company Name: 0/Xt. ( n.5 C--Tit t) 5 Zvzci5S ILL Phone#: (2 �..-9- 6--f
Address:
City:
/.2g G,J 5P-ey 3-20
Ut G State:
Qualifier Name: C)1
State Certification or Registration #: c4C /`53-
DESIGNER: Architect/Engineer:
Address:
Zip: 3 3 3-2-5
Phone#:(7) Y 2 3
Certificate of Competency #:
Value of Work for this Permit: $ S C4), 3/S07. Square/Linear Footage of Work:
Type of Work: ❑ Addition
Description of Work:
City:
Phone#:
State: Zip:
Alteration n New ❑ Repair/Replace
5
n Demolition
way CoLurt,Nvs FoFt ?Q idsc/ 44eouOv 'atF sriltic-rvR6. Due To A
F/t/D Coo Pt TioA7•
Specify color of color thru tile: (lS . r� (`, 0J Submittal Fee $ Permit Fee $ 1 v w CCF $ 2- ' CO/CC $ 0
Scanning Fee $ �� • Radon Fee $ �2 00 DBPR $ 2- - Notary $ 5
Technology Fee $ - . 2-0 Training/Education Fee $ 0 - Double Fee $ 2
Structural Reviews $ (2-p-- C.I. Bond $
TOTAL FEE NOW DUE $ 2•W`i ` 46
(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
j .• 9
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 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
NER or GENT
The foregoing instrument was acknowledged before me this The foregoing instrumen as acknowledged before me this
_ day of , 20 �D by o ((..day of �i ( , 20 by
,who is personally known to ��� W (S �ujtF k'l< 3�tiho is personally known to
�- i T2.16 7 Lap
me or who has produced .fL...)T-2.1 lE(Z L-(Q as me or who has produced
Signature
identification and who did take an oath.
identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign:
Print:
Seal:
r-( N-D! p 'AEU A(2iE-t
****************
040 Po.e Notary Public State of Florida
Sindia Alvarez
oa My Commission FF 156750
of pop Expires 09/03,2018
Sign: 'V
Seal:
Ater Rat. Notary Public State of Florida
Sindia Alvarez
of My Commission FF 156750
o'F Wires 09/03/2018
**************** **Ri��k*** * * **.* * * .* ************
APPROVED BY zv 1" Plans Examiner '71 „
It
-14
Structural Review
Zoning
Clerk
(Revised02/24/2014)