EL-16-2627Al
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 32139
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑ BUILDING I ELECTRIC ❑ ROOFING
7BY
-EC�SEP 2 2 2016
: _
5t n r
FBC 20 /L4
Master Permit No. /X P6 P yaf.
Sub Permit No.-("�- ( 1 _7-0
❑ REVISION ❑ EXTENSION MRENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: (+ a
Folio/Parcel#: Is the Building Historically Designated: Yes v NA
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee
Simple Titleholder):
Titleholder): 8(.wA rA&�r /-� Phone#:
Address: o� 7 Zll A) ice_ _ /&3 6T
City: - /�/C/7'1 i� �%(�/QD State: % Zip: 3�3
Tenant/Lessee Name: Phone#:
Email: A
CONTRACTOR: Company Name:
Address:
hc CD
City: CA4 OL-
Qualifier Name:
State Certification or Registration #:
te:
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State
Value of Work for this Permit: $ ii 0z - a Q Square/Linear Footage of Work: _
Type of Work: 44 Addition
Description of Work:
❑ Alteration ❑ New ❑ Repair/Replace
Zip:
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 011'Si LV ''(;C F $_ ��'
CO/CC $
Scanning Fee $ 3 . G1 Radon Fee $ 3 ,3u DBPR $ Notary $ Q l
Technology Fee $ � Training/Education Fee $ O � _ Double Fee $ 0
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ O
(Revised02/24/2014)
4t
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
Zip
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 approved and a reinspection fee will be charged.
Sig nature GA a, 0 YUAA�&.
OWNER or AGENT
The foregoing instrument was acknowledged beforemethis
22-h� day of �'e0P 011XN 20 l(b by
I VaYCA 'k `Gc�-c�S _`) , who is personally known to
me or who has produced � c) ;+" �:% iSQ6 `f as
identification and who did takes oath.
NOTARY P .
Sign:
Print:
Seal:
P.
APPROVED BY
(Revised02/24/2014)
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
-X 4— day of Sri,Pr 20 /( by
r'2 /4.&440AJ t_0flA t/7-9_ who is personally known to
me or who has produced ID&o2-SoeJ+44(N fi<�,cowARS
identification and who did take an oath.
NOTARY PUBLIC:
v Qlr` Print:
rd
OSCAR PEREZ
YANADYPRIEro Seal:Notary Public State of Florida
MY COMMISSION # FF 214031EXPIRES:March 25, 2019My forum.Expires Oct 4, 2017
8ondedThruNotnyPublicUnderwdtersCommi"lion # FF 052809
anded
iZ -""z s %0 *P4 Plans Examiner Zoning
Structural Review
Clerk