REV-16-880Miami Shores Village
BUILDING
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
RECEIVED
MAR 31.2 16
BY:
FBC 20tq
Master Permit No. k'- (5 -Q 3 j
PERMIT APPLICATION Sub Permit No. ! ,"U 16- 1960
❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
OLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
JOB ADDRESS: -S4 4
CONTRACTOR
(L) C_ -0 U Z,
Miami
`_J
DRAWINGS
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): A-,` 1" L �g,�� I�l� ` Phone#: Q 7 S' a )
Address: LJ g y //�^^,�,�,N�
City: h t�a `4 *s' State: Zip:
Tenant/Lessee Name:
Phone#:
Email: Q V 2iY W2A � A trY1a� l C�,►�
CONTRACTOR: Company Name: E oOy )0tvmkY Sol-vicc. Phone#: 3d,S— 3 3 S
Address: I l a Sy
City: State: tr 1, Zip:
Qualifier Name: E9 D y / /7'Z iN&'2 Phone#:
State Certification or Registration #: 0S % 6 C71 / Certificate of Competency #: _
DESIGNER: Architect/Engineer:
Address: ?_ 300
Value of Work for this Permit: $ a;SUy _ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ElDemolition
Description of Work: c k en S K
Specify color of color thru tile:
Submittal Fee $ �' Permit Fee $ CCF $ CO/CC $ Y�
Scanning Fee $ C,--, Radon Fee $ DBPR $ Notary $
Technology Fee $ �' Z Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 1 G • SO
(Revised02/24/2014)
7
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
WE
City State 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
i
Signature
WNER or AG NT
��The (foregoing instrument was acknowledged before me this
CP--2/ day of 1/► Q (C A 20 1 r6 by
„66
%► k �195@who is personally known to
me or who ha roduce �# JL 1 Uo913 83443--Das
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 6�4)� 9
Print: 0 L- -11\4 G I T-21,mil
, ""'- Ros'yr Citrin
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
a' h day of f'%r G11 20 1�0 by
Gd d •r MC,r i t'\ l— , who is personally known to
me or who has produced 2• I J �'. C I-C- as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: ' 1 � 1 `
Print: ' ' � ty- < < 5t �4 S�1(1 Cl
�°'Y p6$ , Seal: Seal: 4-':Q��
COMMISSION#EE329921 MARLISECASUO
• EXPIRES: AUG, 23, 2016 rh'tt, MY COMMISSION #►EE871338
��°•' WWWAAARONNOTARY.com
EXPIRES: FEB 04, 2017
APPROVED BY e'43`�3 V / - Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)