REV-18-1491Miami Shores Village
Building Department
g p
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC ❑ ROOFING
MAY 31 018
FBC 20
Master Permit No.
t4 C •
- l 0
S
Sub Permit No.
-fV L8
❑ REVISION ❑ EXTENSION [-]RENEWAL
❑ PLUMBING 2IGECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION [:]SHOP
L/p CONTRACTOR DRAWINGS
JOB ADDRESS: (3 7 7 A-9 E 9 9 1%Z
City: Miami Shores County: Miami Dade Zip: 9-)
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
9 �A 3 ,--r - co/Lr'
OWNER: Name (Fee Simple Titleholder): / �'I ( A- n (I S 3 Lj � AJ e Phone#:
Address: � 5 OQ COL-�L--CN 5 %� 2 �,(O `] fNi j /n l 8,PA crl
/FYI.Zip:
City: I I o &A—c-W r L- State: On�'p'0 Zip::1-,�q
Tenant/Lessee Name: Phone#: 8633)_ J 01G
Email: lam/6e . 5(L-15e S7 ecr /1,14 /L. 40n. 3-,(, f � ( L(be,' Z-( ✓ i
CONTRACTOR: Company Name: Q ` )4 rAt/lPhone#:
Address: I- Ol
City:'
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Ad
hone#: QrJ�` 5 �►�'" �� VS
one#:
City: State: Zip:
Value of Work for this Permit: da CA) ,�/ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration LrJ New ❑ Repair/Replace
Description of Work: ' *N 46LAtIowS ���A ✓S� ,*vU j& *+#4 RooM
Specify color of color thru tile:
Submittal Fee $ h Permit Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
❑ Demolition
CCF $ CO/CC $
DBPR $
Notary $
Training/Education Fee $ Double Fee $
Bond $
I
TOTAL FEE NOW DUE $
(Revised02/24/2014)
A
I
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
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 at achment./AIso, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which ccurs',�4en (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approveN n6 reinspection fee will be charged.
OWNER or AGENT
The foregoing instrument was acknowledged before me this
��day of FIL 20 I by
who is personally known to
me or who has produced :FL NVe(,� .I( tt. , eas
identification and who did take an oath.
Signature
_tz
CONTRAC
The foregoing instrument was acknowledged before me this
day of 20J by
tllw 17v t1i who is personally known to
me or who has produced SO A &Un as
identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: "'� Sign:
Print: �►l:��t`'i�( It? 41(;Ji�l(.�ut'Z Print: •
COMMISSION ► FF 206614
Seal: �a`�::.°�kF FLORENCIA RODRIGUEZ Seal: EXPIRES: Match 5, 2019
MY COMMISSION # GG 090164 ' ^; Banded ThN Notary Pubic uNWWwwWm t n
EXPIRES: April 4, 2021
140.4tor 0' Bonded Ttxu Budget Notary Serm
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APPROVED BY ,�Ians Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)