REV-19-9BUILDING
PERMIT APPLICATION
E ,9 ILDING ❑ ELECTRIC
Miami Shores Village RECEIVED
Building Department JAN 022019
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 20V`1
Master Permit No. &F (� � 31q w
Sub Permit No. l a - G
❑ ROOFING dREVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: l Z 6 6 "V V y S T
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1 1 -3L 0 S 0/0 ` 0 / Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): NAP-114 tJDPEi �1�}{L �-I AFL Phone#:
Address: 1 Z(o6 Nez: S-r
City: if 1 � x& at% State: Zip: 3 ��
Tenant/Lessee Name: Phone#.
3.307. 13 !
Email: / XT Ht+7
CONTRACTOR: Company Name: 'NA _r/6 tj%�" �' T �� '✓`BSI Phone#: 3-
Address: 74,23 Sl") l7
2 D
City: /-70 I • '/ State: 'FZ- Zip: 3318 5
qualifier Name: lq-uraeo o Nd a i n Vi5F Z Phone#:
State Certification or Registration #: C�G I q 5-71 U q 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 Zia U I jp l"EN T LOCAr71 01j
2 • 11" IS 5-1-F0 S
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Permit Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/CC $
DBPR $
Notary $,
Double Fee $
Bond $
TOTAL FEE NOW DUE $_• !
(Revised02/24/2014)
1
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
M
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 apd a reinspectionwe will be charged.
Signature
OWNER or AG
The
V"g instrument acknowledged befis
wl-dayof (9&asO L?C -, 20 by
t1F}1211� wpa�eu.YA Hm fr)%,2
o is personally known to
me or who has produced 1P L as
identification and who did take an oath.
Signature
CVATRFCTOR
The fo4%ng instrumentwas acknowledged before jm�e this
C?� D , 20 A by
AC/ " wb(e SXi sonally known to
me or who has produced (— as
identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
d
Sign:
Sign:
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Print: �
Print:
Seal: CRISTINA RODRIGUEZ
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Seal:
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CRISTINA RODRIGUEZ
Notary Public - State of Florida
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o ; Notary Public - State of Florida
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Commission r GG 105164
Commission #. GG 105164
Comm. Expires16, 2021
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My Comm. Expires May 15, 2021
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APPROVED BY Plans Examiner
Zoning
Structural Review
(Revised02/24/2014)
Clerk