REV-19-580Miami Shores Village
Building Department
100S0 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
BUILDING ❑ELECTRIC ❑ ROOFING
Master Permit No
RECE1VED
JR 11 19
BY:
FBC 20 r2�
CC01-Gki 1�uj-1459
Sub Permit No.V�EUJO3 v _ l V0
❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
T'� 4cvt's . Kr'� , C . 3 313P,
City' Miami Shores County' Miami Dade Zip:
Folio/Parcel#:
Occupancy Type: Load
OWNER: Name (Fe ��'
Addr :�_C
City: u
Tenant/Lessee Name:
Email:
Titleholder
o V
cD O
DtM tro- }
-C (bfnvo
s the Building Historically Designated: Yes NO
Construction Type: Flood Zone: BFE: FFE:
(QC'
State:
ne#:C?d-Cq1r- Cf')'q 1--
_Zip: 33 O YD
ne#:l�o —
CONTRACTOR: Company Name: A 12 4J,4- A& Phone#: �f2
Address: I t z I �� % �% e
5.
City: din M 1 State: Zip:
Qualifier Name: �-LC Ci C—` :K Yxal1U?6 (( Phone#:
State Certification or Registration #: 6A6,066 9I®0 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Add
n e#:
City: State:
Value of Work for this Permit: $_, , ' Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of Work:
Zip:
❑ Demolition
Specify color of,.color#hru"tile:- %. '`F z
k, $ 2 6
Submittal Fee $ � `' Permit Fee`$ U • CCF 1 - CO/CC $
Scanning Fee $ Radon Fee $ 'Z DBPR $ --Notary $
Technology Fee $ Training/Education Fee $ 6 • liQ Double Fee $
Structural Reviews $
Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE $
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 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 tFie 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 inspect i ich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not a approv d and a reinspection fee will be charged.
Signature �ignature
R or AGENT vt
k-Npa, gOtt CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of MArC.h . 20 L q by t I day of `AA&Ve-' ` 20 ! 1 , by
C5car 5yUar who is personally known to �AiA a0 JQnca\0 ii%Q , who is personally kno 0
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath
NOTARY PUBLIC: NOTARY PUBLIC: A
i
Sign: Sign:
Print: Print:
Seal- Seal:
KATHERINE RODRIGUEZ .M" Notary Public State a FWds o;....,, ,p
COMMISSION # GG 193438 Janet Lynne Johnson
'G EXPIRES: March 7, 2022 MY CorrrrMa�ion GG 2+ttS20
APPROVED BY
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk