EL-17-1251Miami Shores Village
g
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
BUILDING
PERMIT APP CATION
❑BUILDING ELECTRIC ROOFING
. ,1'\7
MAY 0 8 2017
FBC 20 q
Master Permit No._r%py 1--v
Sub Permit No. EL' » Z6 1
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ 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): Phone#:
Address:
City: State:
Tenant/Lessee Name: Phone#:
Email: I NIL
r
ip:
CONTRACTOR: Company Name: �wc"' / f Phone#: 0 S-J Y 2-6 - FEC72
Address: 3 P, kl-
City: V*tt 19 `t-ti ! State: '�` / Zip:
Qualifier Name: it- K q/' 0l •,,. �✓J� Phone#:
State Certification or Registration #: _ C 0 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ r� Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑. Demolition
Description of Work: ✓l P w ,'�B +^_C' l 7o V ",0011/ ,
Specify color of color thru tile:
Submittal Fee $ D(D 1 Permit Fee $
Scanning 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)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
Zip
Application is hereby made to obtain a permit to o the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit an 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 i
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE
RESULT IN YOUR PAYING TWICE FOR IMI
TO OBTAIN FINANCING, CONSULT WITH Y
YOUR NOTICE OF COMMENCEMENT."
on is accurate and that all work will be done in compliance with all
i RECORD A NOTICE OF COMMENCEMENT MAY
IVEMENTS TO YOUR PROPERTY. IF YOU INTEND
R LENDER OR AN ATTORNEY BEFORE RECORDING
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 commence ent and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copylif 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 reinspectio ee will be charged.
Signature Signature
OWNER
The foregoing instrument was acknowledged before me this
day of Ma 20 n by
G.�.cA," I+ 71d17GC who is personally known to
me or who has produced as
identification and who did t e an lolsrti
inez
NOTARY7wires
ARY.PUBLIC
TE OF FLORIDA
m# FF950260
Si n:
g
1/13/2020
Print: kanaw /v!/X✓a16121
Seal:
CONTRACTOR
The foregoing instrument was acknowledged before me this
!;-- day of 20 1 2 by
-, who is personally known to
�EA,me or who has produced k -, as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
� � U- - notary p�blk - State of Florida Seal: '����,r
My� mmisslonp0G09�t7
Expires Apr25, 2021 d�ded through
Natioiyt Notarygs�
APPROVED BY s%Z 29" Y % Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)