DEMO-03-19-589DtmP, 9� CA-�
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BUILDING
PERMIT APPLICATION
Miami Shores Village M 18 2019
Building Department BY:
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795 2204 Fax: (305) 756-8972 lit
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INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 ��
Master Permit No -MHO' 0-3- )CT-59 1
Sub Permit No.
[�OUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION SHOP
�j% C CONTRACTOR DRAWINGS
JOB ADDRESS: Y `� � y —
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: �, I Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): � MJ�� Pone#:
Address:
City:
Tenant/Lessee Name:
Email:
State: Zip:
Phone#:
CONTRACTOR: Company Name: Phone#:
Address:
City: State:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #
DESIGNER: Architect/Engineer: Phon
Address: City:
Value of Work for this Permit: $ 50`� 'Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/place
E
a
Demolition
Specify color of color thru tile: �-yo-�
Submittal Fee $ Permit Fee Ao•cp CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUES— ' "�
(Revised02/24/2014) Q I . e-'2' 0
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
CE
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."
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Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $1500, the applicant must
promise;in�good faith that a cop of the notice of commencement and construction lien law brochure will be delivered to the person
whose"property is ject to at ac ment. Also, a certified copy of the recorded notice of commencement must be posted of the job site
fo Se first inspe ti n which occ rs seven (7) ays after the building permit is issued. In the absence of such posted notice, the
`�.
rr spedion will no be ¢prove a d a reinspec on fee will be charged.
Signature
OWNER or AGENT
Thet foregoing instrument was acknowledged before me this
day of :YNoapi •'l 20 1!) by
Y
'[M.C.�—p►`=�� 3"1n7h�f5 pers al n to
T.
me or who has produced as
isle' i;if catiX and who did take an oath.
NQ.TgRY PUBLIC:
Sign:
Print: �r Marcho2•_�
Seal:
iBn ;6ii�'yrhN
APPROVED BY
(Revised02/24/2014) s
e
Signature
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:
Sign:
Print:
Seal:
Plans Examiner
Structural Review
as
Zoning
Clerk