REV-16-2113Miami Shores Village
t� g R-ECEIVED
Building Department JUL 27 2016
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 I
Tel: (305) 795-2204 Fax: (305) 756-8972 lBY'
INSPECTION LINE PHONE NUMBER: (305) 762-4949 �-I-h
FBc 20�4
BUILDING Master Permit No. l' & 9 —15 — 33�
PERMIT APPLICATION Sub Permit No. P� 1-1 b -- D 11
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: eyiZ/JN� o ti / pu 2Si67
Citv: Miami Shores Countv: Miami Dade ZiD:
Folio/Parcel#: I f - 3 2 O U " O 17 -/ 4 iy Is the Building Historically Designated: Yes NO
Occupancy Type: Z:5— Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 1"f S L C d {� A73ES5 / as Phone#: q I7 -G �7- D 71
Address: _� 4g (; aA CD 3� ti C/0 L7 IZ
City: VVI, k n' \.-,- \ t, 0 CLC.s State: Zip: :3 R
Tenant/Lessee Name: f_ ^ Phone#:
Email: %�/��`t✓Ujyi�N1��2 (�y�7Z��(� �t ��( . r— U�
CONTRACTOR: Company Name: W R 0 11 (f 0 K-3 % 1 2 U CA) Phone#:7 �b "� 1 'D T
Address: _ � `� O 1 S L-3 ) R "-,1 S+
City: h-` `.mot � State: v� Zip: 3 17 S
Qualifier Name: 2 0 1) A \^ (!�n D 2 fIJ U�� /� � c7 Phone#:
State Certification or Registration #: C G-G !� LZ 9 �i Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace
/ ❑ Demolition
Description of Work: �- L(0 Q D A fZ ^ ui l M O f Z L A ( o
o 0 (Z L) CA) v ti. n_ 4-f 1, CC T W-k-
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ OD CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Structural Reviews $,
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $
if
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 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—ofabsence—of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatur4 Signature �" D
WNER or AGE T
The foregoing instrument was acknowledged before me this
13 dayof _- a u ty 2016 by
4 6ff3 who s personally know
me or who has produced
as
CONTRACTOR
The foregoing instrument was acknowledged before me this
13 day ofCt IV 20 16 by
90d h 10 0 /� �.! Q, w► b S who i personally know to
me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: P(/G Sign: C/
Print: fl✓-j._y'' I -, _ Grp T�r%4 1 L I I I 1�1 Print: I'C 0S1, Y q G1 7)If>>./
Seal: �`CUMMI ra �"ll� ,,,
a51„l;!�EE829921 Seal: cotYPOo-; Rosl n
EXPIRES: .r; G- y �• Cltrin
EXPI
COMMISSION # EE829921
WWW.AARONNOTARY.com EXPIRES:AUG,
'� of 23, 2016
WY✓W.AARONNOT ARY, o
jl
APPROVED BY ,V /4 Plans Examiner Zoning
Clerk
(Revised02/24/2014)