ACT-18-3550BUILDING
PERMIT APPLICATION
Miami Shores Village
RECEIVED
Building Department NOV 28 2010
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BC 20
Master Permit No. ff C-T Q
Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
// CONTRACTOR /� DRAWINGS
JOB ADDRESS: /3%iL� N� 2�� Q-AAe(A A� All, J�' (/4-
Folio/Parcel#:
Occupancy Type: Load
OWNER: Name (Fee Simple Titleholder):
Address: / ff1t,Sb�
City: q
Tenant/Lessee Name:
Email:
Is the Building Historically Designated: Yes NO _
Construction Type: Flood Zone: BFE: FFE:
/ /Y
one#:
State: H-L Zip: `33 16 1
on
CONTRACTOR: Company Name: A'En 4� \ l i L G Phone#:
Address: cb )-9 S w-e 5T 2 m�
City: /-/ «'
Qualifier Name: _
te: r—
Zip: 3-�o / Y"
hone#: 4� S `/ -�7 S
State Certification or Registration #: `� (3 ! Ali S'OD Certificate of Competency #:
DESIGNER: Arch iittect/Engineer: evi .?-✓ I e6-Phone#: `�
Address: -.11y ?10 5 w 6 51T ![-� City: %a pf State: Pam- Zip: 3�3)
Value of Work for this Permit: $ L-) . c)o Square/Linear Footage of W I �J
Type of Work: El Addition El Alteration New ElRepair/Replace 4 ition
Description of Work: T l -P � 9
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/CC $ _
DBPR $ 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
Zip
Zi
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 d I' nce with all
applicable laws regulating construction and zoning.
WARNING TO OWNE • YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMEN�AY
R. OU
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 reinspgction fee will be charged.
.1Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
Zglw day of V LVEtti96q, 20 0 by
JA(A hj i,()S bJJrVA V who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Print: ' '.i
Seal: £ +5:! JEFMIYAO
CWA11aion#00249916
elql" kombet IIZ 2422
s,
APPROVED BY
The foregoing instrument was acknowledg or as
day of 2`e 20 by
(-qe2rn who is personally known to
me or who has produced �17 ,D as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 4
0 Print:
Seal: 4,,,0;
r Notary PubliC State of Florida
Jennifer Hill
My Commission GG 163760
Expires 11/28/2021
***************************************** ***************************
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk