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REV-17-153Miami Shores Village r- Building Department artment , 10050 N.E.2nd Avenue, Miami Shores, Florida 83138 Tel: (305) 795-2204 Fax: (305) 756-8972 13Y: INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING X ELECTRIC ❑ ROOFING f�` F3"v J 9 2017 FBC 20(7-v "fiL Master Permit No-f�C ` I� 2 Sub Permit No. kV i — 17 S3 �4 REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 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):_ CON OUI2Se Tom '[" Phone#: -3dr�2 -+67q - 1 0&2 Address:. �2O1 6i,YZA" 1% � N (-QU12SC 2 City:�I &K ` e: (001(� 5 State: �� 2 Zip: Z/Z2 I JL_ Tenant/Lessee Name: n �m� /� Phone#: Email: ��SS l � WA (i /i CONTRACTOR: Company Name: QCLL2 XIC ' C 7 Phone#: ?G " 25-3" Lf 1 3 9 Address: =7 7 6 F . 4 2 s. City: 42 4 114 A j State: 44� Zip: 333 0l Qualifier Name: 2tifN A4 14y a Phone#: State Certification or Registration #: d'G 300 D.4� 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 ❑ Alt'er11ation ❑ New 1❑ Repair/Replace ( ❑ Demolition Description of Work: ��% ��0 W Q — K.t�l, ©l \ ✓� ��Q ( fi ov -a �, aGu cT `LA -1 o K3 t-= - Specify color of color thru tile: Submittal Fee $_ ✓ Scanning Fee $ _ Technology Fee $_ Structural Reviews Permit Fee $ d CCF Radon Fee $ Training/Education Fee $ DBPR $ CO/CC $ Notary $ _ Double Fee $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ 3-76 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the_ inspection will not be approved and a reinspection fee will be charged. Signatur OWNER or AGE T The foregoing instru ent'was acknowledged before ejtthis r day of J a- R\,t a r, 20 17k by jt S 3 who��Awto me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: 4� kaz�4 Print: mA14- �&L)ARLe- l Seal: Notary Public State of FWda Marc Goldberg M CommiWon GG 015050 t Signature " A CONTRAC OR The foregoing instrum 1 was ack wledged before me this day of 20 6 " by me or who has produced v�ko is personally known to as identification and who did take an oath. NOTARY PUB Sign: Print: Lair I—a7Wd.,VD 2— �1►x� W S FEMM M Seal: my commiSSION # EE 838180 * EXPIRES: November 7, 2016 Bonded Thru Budget NotaY Sevb$ Y Wires 07/25/2020 *********** * * *************e***************************************************** APPROVED BY Plans Examiner Zoning (Revised02/24/2014) Structural Review Clerk