REV-17-2531Miami Shores Village
Building Department RECEIVED
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 CT 2017
O INSPECTION LINE PHONE NUMBER: (305) 762-4949 5
FB c 2 au
BUILDING Master Permit No.'-Qr—C ?)
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING �EVISION ❑ EXTENSION [—]RENEWAL
❑PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
/ l —CONTRACTOR DRAWINGS
JOB ADDRESS: 4— 'v Lx J Iy 1
City: Miami Shores County: Miami Dade Zip: �CJf
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
_ � n I r-.one#: ��0 I �39OWNER:Name(FFeeSiimpleTitleholder):i
Address: ' (0 (9 1 i
City:
State:
P: .3:�1 �
Tenant/Lessee Name: Phone#:
Email: ��I�viy C_V� QJ�J\O� . CDM
CONTRACTOR: Company Name: --�t�� �O1� IU-76&Phone#: - =J 221 (,0
Address: Yl
City: k-A— \ 0.A Q
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/En
Address
Value of Work for this
Tf L Zip:
Certificate of Competency #: t �/
City: State: Zip:
Square/Linear Footage of Work:
Type of Work: ❑ Addition f❑ Alter tion ❑ New ElRepair/Replace ❑ Demolition
Description of Work: �t—e L' GQ1 1 OVI 7�� C- �0C'--1-
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $
Technology Fee $
Radon Fee $
QPCCF $ CO/CC $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Structural Reviews $
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $ �—
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
K.
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: 1 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 appyeyed and a reinspection fee will be charged.
Signature Signature
UVVNtK or CONTR CTOR
The foregoirfg instrument was dicknowledged before me this
a 3' day of C 4ub a4- , 20 1 by
qUd ku,P S JI MP► ifA— who�s personally known to
or who has produced as
i entification and who did take an oath.
NOT
Print:
The foregoing instrument was acknowledged before me this
day of c '�Db-Q - , 20 (-�- by
i`-VG Id0 RtQ C-) who is(personally known to
me)b�rwho has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal: '07
M1' OOMMISSfe�l 916836 Seal: _My00MWSSI0I#FF9166X
***********************************************************************************************************
APPROVED BY P�ns xaminer Zoning
Structural Review Clerk
(Revised02/24/2014)