EL-18-34 (2)Miami Shores Village
Building Department
JAN 0 4 2018
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 201
BUILDING Master Permit No.'�?_ L 1 �� ✓ 2—
PERMIT APPLICATION Sub Permit No. P_ 1 '':;q
❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
n1 (� CONTRACTOR DRAWINGS
JOB ADDRESS: r I 'V C -1 ST
Citv: Miami Shores Countv: Miami Dade Zio:
Folio/Parcel#: ( I- 3aLYa -V .3' 1 C) 10 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): H 7 -R0 IU ,y 04Phone#: Goc - "• 6-Icz
Address: -4 ST
City: J�A ��'�`-� I Skel r—* State:
Tenant/Lessee Name:
Email
p: 33138
CONTRACTOR: Company Name: `F `alms a'E]=7P-4rAk_ QQR_:� Phone#:
Address: (2.. n 3 SW en_rl"ft-
City: State: - Zip:
Qualifier Name: —i
State Certification or Registration #:
DESIGNER: Arc-h-iitectct/EEnngineer: -46
Address: j
Value of Work for this rmit: $
hone#:
Certificate of Competency #:
e7�isdN Phone#:�-(:,�3/8
Cit� � �ate:-"R_ Zip:33
Square/Linear Footage of Work:
Type of Work: Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
,,'
Description of Work:A X-MCt :t� O
om
Specify color of color thru;.tile: ' °
Submittal Fee $ Permit Fee CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised 02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
E.
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 approved and a reinspection fee will be charged.
Signature
Z'Z
OWNER or AGENT
The foregoing instrument was acknowledged before me this
Zf"! day of —,V�, 20 ( , by
who is personally known to
me or who has produced (7N 1'1 as
identification and who Hid take an oath.
NOTARY PUBLIC:
11
Sign
Print:
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
�2'q day of col VY1 �Y 20 l- by
tYGt►�1G15Gp pf rGZ who is personally known to
me or who has produced DL nr► f� I.G as
identification and who did take an oath.
NOTARY PUBLIC;
Sign:
Print: S
NANCY IGLESM
Seal: * * MY COMMISSION # FF 116314 Seal:
EXPIRES: May 20, 2018
Bonded Tin Budget Notary Services
APPROVED BY _/�1,9 Plans Examiner
Suyapa T. Vasquez
Commission # FF942611
Expires: December 9, 2019
,'V * Bonded *hru Aaron Notary**************
Zoning
Structural Review
(Revised02/24/2014)
Clerk