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REV-16-879Miami Shores Village 7BY: _ Building Department 31 2 16 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20rq BUILDING PERMIT APPLICATION ❑ BUILDING N ELECTRIC ❑ ROOFING Master Permit No. - ,C- / k �� 1�� I k Sub Permit No. Y 1% ` s I ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: S �� G(w /-)-b r a tV C-- © U i z S G (3 Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: FE: FFE: fi�,o S OWNER: Name (Fee Simple Titleholder):. PhoneM k�E1 Address: 6 ka Q C S City: �VLSN.\ State: Zip Tenant/Lessee Name: Phone#:• -- Email CONTRACTOR: Company Name: ©Je- �e le , ku r rom Ax-) y Phone#: 3415' 883 -066C Address: ? ZJ1 6 E / 3 Z 5.4 City: ! / c `6 be .a [^ State: Flm2fc,�A Zip: 3,3 c 13 Qualifier Name: Z U l-S 0-o o 14 Phone#: ti State Certification or Registration #:C l > DO �_' 03 cS Certificate of Competency #: DESIGNER: Architect/Engineer: �7' c� ` _ C p1�6�� A g-sr�C , Q 4c- 4 Phone#: l _1 �/ 17 / 1b 10 Address: Z� kit City: P6&4 PAML-State: Zip: 0 Value of Work for this Permit: $ 'T�� Square/Linear Footage of Work: t3 Type of Work: ❑ Addition Description of Work: l\ W1 a d Alteration ❑ New ❑ Repair/Replace (❑ Demolition f;-C`TC1Cb (-- O0�-'e\�- CP CTLI1,1 Specify color of color thru tile: Submittal Fee $, 0 Permit Fee $ /.Y'O�p� CCF $ `-i - �RD CO/CC $ Scanning Fee $ 3-Q Radon Fee $ a - DBPR $ ' �S Notary $ Technology Fee $ Training/Education Fee $ Structural Reviews $�f�_ _ M Double Fee $ (71 Bond $ 91 TOTAL FEE NOW DUE $ l '-1O , 30 (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State WE 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 of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signatu OWNE or AGENT The foregoing instrument was acknowledged before me this IL;Iday of MO. Mr 20 by t° j`• Se 4&5, who is personally known to me or wfio ha roduce- FL bL 140;200/3939Y3 ifs o ' Signature Z t,i` U A CONTRACTOR The foregoing instrument was acknowledged before me this L day of a//� 2016 by me or who has produced who is personally known to as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: 4� Lli►ti— Sign: Print: ( �, yN , _ t;J ,.,�� 1 rye X Print: L f / l414)G'Y Seal: `?° �=COMMISSION#EE829921 Seal: i"aYP 'Z EXPIRES: AUG. 23, 2016 : � LUIS FERNANDEZ °,,-,,°;,;;°�� www.AARONNOTARY.COM * , My COMMISSION#EE888180 EXPIRES: November 7, 2016 P",004 Th, u Budget Notary serwhs ************************************************************************************************************ APPROVED B tf4 , &I I l fans Examiner Zoning Structural Review Clerk (Revised02/24/2014)