REV-17-2589Miami Shores Village
Building Department RECEIVED
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 'T "7
INSPECTION LINE PHONE NUMBER: (305) 762-4949 5
FB0201`4
BUILDING Master Permit No. Y
PERMIT APPLICATION Sub Permit No. W
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
Op LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
Al
K) CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:T� �1 �z�� - 0 [0 U Is the Building Historically Designated: Yes NO
Occupancy Type: _ Load: _ Construction Type: Flood Zone: BFE: _ FFE:
OWNER: Name (Fee Simple Titleholder): ✓I IC C1 —U✓rtiG ✓► Phone#:
Address: i z-C-1 A)L,,-J q 6 5
City: A6 k o^ I State: L Zip: // 1 S-1y d�
Tenant/Lessee Name: Phone#:
Email: 0i 4'''1 c jC _ W /W
CONTRACTOR: Company Name:1( U �� t l ► phone#: -O)2
Address:, ( w -4- 2 T
City:
Qualifier Name:
State Certification or Registra
DESIGNER: Architect/Engineer:
Certificate of Competency #:
hone#:
Address: City: State:
Value of Work for this Permit: $ 0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of Work:
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF
DBPR $
Zip:
❑ Demolition
CO/CC $
Notary $
Double Fee $ _
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
'Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
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 approved and a reinspection fee will be charged.
Signature
O R or AGENT
The foregoing instrument was acknowledged before me this
day ofp )L+- , 20i {�� , by
�-1°.`� �1 1 ��Y�^;'3@s'pePor al; known to
me or who has produced z as
identification and who did take an oath.
Signature MW �--6 A",-�
CONTRA R
The foregoing instrument
//was / acknowledged before me this
day of PC to 20 by
J who is personally known to
me or who a`tn as
identification and who diet takelan oath.
NOTARY PUBLIC: NOTARY PURL
rnAHARaIIc.GrIJ2ALEZ
,/k
n. *" :qY CGNI AIS°'.ON i GG 044602
EXPIRES Hove ,bet 2, 2U20 $j
~ :FOP F4� ' 3cnd -.i Ti.: Nrlary ?ublic underw iters
Print: t: f' �—
Seal: Seal:. MY COMMISSION #FF1 98880
�ri►� EXPIRES: FEB 1$, 2019
as Bonded through 1st State Insurance
APPROVED BY '� Plans Examiner _Zoning
Structural Review Clerk
(Revised02/24/2014)