EL-14-1411BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
RECE1VI.'.. ,
JUL 01 2 4
�� FBC20
Master Permit No. I2'Li� "'I1� 10
Sub Permit No. F7L—j'-�— 14 C
❑BUILDING
NTLECTRIC
❑ ROOFING
❑ REVISION
❑ EXTENSION
RENEWAL
❑PLUMBING
❑ MECHANICAL
❑PUBLICWORKS
[:]CHANGE
CONTRACTOR
❑ CANCELLATION
❑ SHOP
DRAWINGS
JOB ADDRESS:?, gq N.C. j 0 7 SF:'
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 24 C. Ari will idjo (.L L Phone#: ?20 ? ZE 266
Address: 7 f5i NG 1,0 e+ .1 %
City: 2L4 Ipwt( 5J40& 5 State: ^14-111 Zip: 3313f
Tenant/Lessee Name: Phone#:
Email
CONTRACTOR: Company Name: f340 SA o V a\,e A kj' L Q� rV G Phone#: 30
Address: G l U S W 1.l`l I
City: t o w` . State:
Qualifier Name: w►.n .w .i.e
State Certification or Registration #: L__1
DESIGNER: Architect/Engineer:
p: 33t7%(
hone#: i 9' ( 3 0 7 Y Z S i
Certificate of Competency #:
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 60 o Square/Linear Footage of Work: 3SIa
Type of Work: ❑ Addition Alteration ` ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: lA/1d21dA_ RL/e�DOe�Ctillr . �iTC.i7ed1 ;�jLl1
Submittal Fee $
Scanning Fee $
Notary $
Permit Fee $ IY2470'®® CCF $ CO/CC $
Radon Fee $
Training/Education Fee $
DBPR $ Bond $
Technology Fee $
Double Fee $ Structural Review $ c
~ 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
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 ELECTRICA_`WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 anrestimated 'value exceeding $2500,,the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure -will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reins ection fee will be charged.
Signature Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this r The foregoing instrument was acknowledged before me
C
day of �� 20 "1 by t 1 ff this—�-U2 day, of 20 & by 40 L4: Leon
who is personally known to me or who has produced 'whoWr`•known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: �.�``O-hOijI'do NOTARY PUBLC:
Sign: -
Print: , 9dOZ/90l�Q ,
My Commission Expires: //s!'r$'i�a�1a\\\.�`�
Sign:
Print:
MyC
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APPROVED BY �!/L V Plans Examiner Zoning
Structural Review
Clerk
(Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/30/2009)(Revised 3/15/09)(Revised 7/10/2007)