REV-18-3292Miami Shores Village T�m
Building Department c���cr�
OCT 2 s 201$
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 BY.
INSPECTION LINE PHONE NUMBER: (305) 762-4949 r1l TT
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL ❑PUBLICWORKS
JOB ADDRESS: f z k):E� <3L� s '-z' &
W 2Q-4
Master Permit No. (2.(— V3 ?—
Sub Permit No. 1,-C- yy,0-: �'l Z
C2(/REVISION ❑ EXTENSION [:]RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip: �>313Q
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: /� J Flood Zone: BFE: FFE:
OWNER: Name (Fee Si ple Titleholder): �Yvv C�`'—' — rfi:( Phone#: je6 2-YO Q
Address: 1q111 �o '►�S � :�'i0-2--
City: State: C L` Zip:
Tenant/Lessee Name: Phone#:
Email
CONTRACTOR: Company Name: Pb1— Vl� Phone#:
Address:
City: State: Zip:
Qualifier Name:
State Certification or Registration #:
Phone#:
Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#: _
Address: City: State:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Zip:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
n
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 0' CCF $ CO/CC $
Scanning Fee $ 2, 00 Radon Fee $ DBPR $ Notary $
Technology Fee $
Structural Reviews $
Training/Education Fee $
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
Zip
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 ins a do which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will n t e roved and a rein pection fee will be charged.
Signature Signature
I OWNER or AGENT
The fore oing ins trument0aYatknowledged before me this
21 day of S*C ramr 0 q 0 , by
rDQho is personally known to
me or who has produce
identification and who did n oath.
NOTARY PUBLIC:
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of , 20 , by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Si SSign:_
Pri ; ;;�; oq MAHARAI K. GONZALEZ print:
EXPIRES: November 2, 2020
� �a; Seal: Seal:
o. ���P' Bonded Thru Notary PuNic Underwriters
as
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)