PL-17-2809Miami 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 ELECTRIC ❑ ROOFING
ErOLUMBING ❑ MECHANICAL PUBLIC WORKS
JOBADDRESS: 12.F) NE Icy! 5
City: Miami Shores County:
Folio/Parcel#:
I I -32o5- 00S -00,3n
Occupancy Type: Load: Construction Type:
❑ REVISION
REC
BY:
FBC20' 1si41
`Master Permit No. P)C.- 17 - 2-
63 Z.
4 Sub Permit No. Pt f - O 9
❑ EXTENSION ❑ RENEWAL
❑ CHANGE OF• ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Miami Dade Zip:
Is the Building Historically Designated: Yes NO
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): (iiQC IQ Mr_ (3,atnn-ess 11ei) es,?:(3) 34Z-ii 1 ZAddres: �a5C) NEp%
city: tY1 am nInores
Tenant/Lessee Name: Phon
Email:
State: FL_
CONTRACTOR: Company Name: ^.Iblor,
Address: IOLQ0 5 r-.H xt
onpc PLC trinAnin0
City: f 1-}rnllyv)i-f-'cj State: EL
Qualifier Name: John 3or r5
State Certification or Registration #: Ci FG O -Into 7
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $ 000
Type of Work: ❑ Addition ❑ Alteration n New
Description of Work: 4ric u Qe'f+ Pit ii A rY1\(D i
Phone#: O
Phone#:
Zip: ?)?C3e) I
{ Certificate of Competency #:
Phone#:
City: State: Zip:
Square/Linear Footage of Work:
Ii Repair/Replace n Demolition
el x4t i re i t •K t 1c n
Specify color of color thru tile-
•
(e.
'CJ I
Submittal Fee _ 1 L Permit Fee $ 6 CCF $ CO/CfrA_______
Scanning Fee $ Radon Fee $ 2 • a DBPR $ 2 • 2- E Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE$ t10 . 45
(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: 1 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) 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 Signature
OWNER or AGENT
ONTRACTOR
The foregoing instrument was acknowledged before me this The fore: • ing instrument was acknowledged before me this
.:2-1 day of NW) V , 20 I -7 , by 2 day of ivza .
N'e t 1 f c Eltitnn,e SS , who is personally known to kl t\ x( A,.. ‘
me or who has produced 0.r/as me or who has produced y i ..A.r LAC_
identification and who did take an oath.
ide , ificatioand who did take an oath.
NOTARY PUBLIC: NO
Sign:
Print:
Seal:
APPROVED BY
Sig
Print:
Seal:
fl 24 L Plans Examiner
COMMISSION # GG 120628
a;
_� b; PIRES: October 30, 2021
. F; 10 Bonded Thru Notary Public Underwriters
, 20 l ) , by
, who is personally known to
as
Zoning
(Revised02/24/2014)
Structural Review
Clerk