PL-18-1626BUILDING
PERMIT APPLICATION
❑ BUILDING
LUMBING ❑ MECHANICAL
JOB ADDRESS: / 5-78
City:
Folio/Parcel#:
Occupancy Type: Load: Construction Type: Flood Zone:
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
❑ ELECTRIC ❑ ROOFING
Master Permit No.
Sub Permit No.
FBC 2011 tip-►,
PPP 6- 1g- (623
Pt_ ig-i(16
❑ REVISION ❑ EXTENSION
❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
l�7 Se —
RENEWAL
❑ SHOP
DRAWINGS
Miami Shores County: Miami Dade Zip: 3_ /1/
//- Z / 3‘ - 0 Q 2-02-Qgs the Building Historically Designated: Yes NO
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 5 /fg' 1,1 Y/9A1 Phone#:
Address: / SO Q 7 ` 6-
City: ////YJ
%12,4-5 State:
Tenant/Lessee Name: Phone#:
Email:
Zip: 3 3 /1/
CONTRACTOR: Company Name: e'S-,a0->r//p7/9/ D0/4 - 2 Phone#: 5 0 a
Address: 2.--27 ,' y/ 4-/c%•,7/v J -/v "ram
City: •i41,6 49 X 6' //yt7,-SState: >-1...-- Zip: 3 3'V29
Qualifier Name: p/67' 144 to 6z- Phone#: 737/ 1-Y772.O'
State Certification or Registration #: CPC / yrGi7d' Certificate of Competency #:
DESIGNER: Architect/Engineer: \//G Eit/7 Phone#: 'S a `r 3l, J' c — 6 3
Address: / a7 7 6 /may!/ r 4 WW/15- -S-- City: ////5i0V i
Value of Work for this Permit: $ / bo 0—
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration Z-New ❑ Repair/Replace ❑ Demolition
Description of Work: e vi,/`1 Lx7- ,aim7 /14,/t/d; 4 7 i J5iI,1�, /v.6-•
State: r Z Zip: 3•3 /7--g
Specify color of color thru tile:
Submittal Fee $ S6 Foal a Permit Fee $ �s CCF $
Scanning Fee $ Radon Fee $ a- oZs DBPR $ •36)
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE$ ( & `� • Z-3
CO/CC $
Notary $
(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) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be appro "d and a reinspection fee will be charged.
Signature
OWNE
The foregoing instrument was acknowledged before me this
12 day of j VA/ , 20 1 $ , by
fikrq{t tr. S u LLI J tJ , who is personally known to
me or who has produced f Z. 4 e'ti Eit as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: Lr
Seal:
GLORIA E. VANEGAS
MY COMMISSION # FF 926723
sc
2019
e,R;t,•Bodd Thru Notary Pub c UndIRES: November enaiters
442412,A7 a://-6-e
The foregoing instrument was ackno edged befolr e this
day of ► \/`� , 20 l , by
l'tO G t ho is
personally kn n to
by6 or w has produced 1 as
identification and who did take an oath.
NOTAR BLIC:
rpm
Print:
Seal:
•`o',Vt4;o'•; MAHARAI K. GONZALEZ
.�. MY COMMISSION # GG 0446Q2_
4.9Air,s EXPIRES: November 2, 2020
Bonded Thru Notary Public Underwriters
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APPROVED BY
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk