REV-19-638BUILDING
PERMIT APPLICATION
❑BUILDING ELECTRIC
❑ PLUMBING
JOB ADDRESS:
Miami Shores Village RTE- EBVED
Building Department MAR 25 2019
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
QFBBC
Master Permit No.
Sub Permit No. (�� o3
❑ ROOFING ❑ REVISION EXTENSION RENEWAL
LAECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
_ CONTRACTOR DRAWINGS
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: N me (Fee Simple Titleholder): A� �'� Phone#:q1jj 4 '9 (4 ' '-ff
Address: Iv v \ 0 1 '
City: �� �w` ` State: r 1 t� Zip: Js t ✓ q—
Tenant/L/e�s�se�eyN�ame: �` � /� 1 Phone#:
Email: V I ��-+ I�C� C-e ��/Q 1
CONTRACTOR: Company Name: B t9 (/ �l/ Phone#:
Address:, ^S
City: V`�' 1 (� State: ���// ZipQ:f /
Qualifier Name: PC 1 J 1 �`�! �' Phone#: s) Q'C�!�
�l�f 63c —T
State Certification or Registration #: � 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: ❑ A itio.n1 �❑ Alteration ❑�N/e%w /Repair/Replace ❑ Demolition n 1
Description of Work:
Specify color of color thru tile:,
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
Permit Fee $ 776 CCF $_
Radon Fee $ DBPR $
Training/Education Fee $
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 3 1
(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
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 of be approved and a reinspection fee will be charged.
Signature lJl Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
ZS day of G �C h 20 . by
Q�Aon i co fd'TQo is personally known to
me or who has produced -I 1�(� ��� as
identification and who did take an oath.
NOTARY "LIC:
MAHARAI K. GONZALEZ
Print: 2'
a EXPIRES: November 2, 2020
Seal: Bonded Thru Notary Pub
lic underwriters
The foregoing instrument was acknowledged before
'mee�this
S day of Q i�F' ` 20 1 l , by
����i ( 1ho ' ersonally known to
me or who has produced Qyn e- as
identification and who did take an oath.
NOT
Sign
Prin'
Seal
APPROVED BY V tans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)