DS-16-2670 (2)BUILDING
PERMIT APPLICATION
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
❑ ROOFING
❑ PUBLIC WORKS
JOB ADDRESS: t 2 6 N l Z 5-1--vczE
City: Miami Shores
Folio/Parcel#:
Occupancy Type:
RECEIVED
AUG 16 2017
FBCc20 Ir Master Permit No. PS l "df�� 2C, t1
o
Sub Permit No.
❑ REVISION
❑ CHANGE OF
CONTRACTOR
EXTENSION
❑ CANCELLATION
❑ RENEWAL
❑ SHOP
DRAWINGS
County: Miami Dade Zip: '33 ( 3
Is the Building Historically Designated: Yes NO
Load:
OWNER: Name (Fee Simple Titleholder):
Address:
City: kk1 S L7 V cS
I , Construction Type:Flood Zone:
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State: �L
Phone#:
BFE: FFE:
(i$4)2n 3C1 L
Zip: :5 1 '5 t
Tenant/Lessee Name: Phone#:
Email: \/A--ct"N-; 611k Lo&.
Co
CONTRACTOR: Company Name: U�/ .t t G C� Q c� ( � L Lc_ Phone#: C l d' b 1 S 11 T 1 }5
Address: Ce to e, 5,Ji k P
City:
Qualifier Name:
State:�--
•
Phone#:
Zip:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: , Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration
Description of Work � ' 1co
❑ Repair/ R place ❑ Demolition
cam. -f t.*
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Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
CCF $ CO/CC $
DBPR $
Notary $
Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE $ - Q
(Revised02/24/2014)
Bonding Company's Name (if applicable)
r
Bonding Company's Address
City y `, ' State Zip
Mortgagelender's Name (if applicable)
Mortgage Lender's Address
City 1 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. t
"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 building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
r
1
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
_1 day of P o , 20 byy' Le day of�1k J, 20 1 , by
t `� , G 1 ter l4.--;16
tz� O are, , who is personally known to
�Q P � 1"
me or who has produced ` t s me or who has produced n um as
identification and who did take an oath.
NOTARY PUBLIC:
Sign.
Print:
Seal:
MAI IAR11I K. GONZALEZ
MY COMMISSION # GG 044602
EXPIRES. November 2,2020-
%o ; op', Bonded Tlvu Notary Public Underwriters
identification and who did take an oath.
NOTARY PUBLIC:
Sig
Print:
Seal:
MAHARAI K. GONZALEZ
IT'WMMISS ION # GG 044602
EXPIRES: November 2. 2020
e. Notary Public Underwriters
.............................. ........................................................................
14
APPROVED BY
/7
Plans Examiner
Zoning
Structural Review Clerk
(Revised02/24/2014)
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RECEIVED
AUG 18 7I117