REV-17-1895Miami Shores Village
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
J Lt 2 5 2017
B ,
PSI �3 FBC 20IQ
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No. 1L1��I c�t
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
UMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: CIW� Nff �(- LS� `
City: Miami Shores County: Miami Dade Zip: 1�&�R
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: ]Flood Zone: BFE: FFE:
OWNER: Name
(Fee Simple
1.Simplle`Titleholder):/ (� �AkZzn)Li Phone#:
AddresO'cz • /V —Vtn2.
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: c�< � �I1, ��, 1'-•1 Sv one#: /g (b �0 ���
Address:2423 9 �C�+
City: State:
�� Zip: Z ZL 6J
Qualifier Name: � Phone#:79&4%�
State Certification or Registration #:. .1`"�Okla Z 7 2 26 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: � j
Square/Linear Footage of Work: l J9�
Type of Work: ❑ Addition. `❑ Alteration ` ❑ New ❑, RReepai,r/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ Permit Fee CCF $ 00 CO/CC $ jo
Scanning Fee $ W Radon Fee $ 'c�T '49 DBPR $ CI , Notary $
Technology Fee $ t Training/Education Fee $ Q' 2 Double Fee $ Aer
Structural Reviews $ Bond $ )`''
TOTAL FEE NOW DUE $ S V
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
. A Li
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 o a building I 1 pp f g permit., wiCh�an estimdted•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 posi4afthe 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 V 't
OWNER or AGENT
. � T
The for going instrument• as acknowledged before me this
2 day of by
who is persona nown to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Print<1�.
Seal: Jorge Ortigosa
Notary Public State of Florida
FF 952774 - Exp 02.07.2020
Signature
CONTRACTOR
i
The foregoing w instrume t a acknowledged before`mme this
' a ' of �� ��/ p ` l / by
l 1 ho is perso known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Jorge Ortigosa
Seal: Notary Public Stale of Florida
FF 952774 - Exp 02.07.2020
as
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)