REV-18-56Miami 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
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC ❑ ROOFING
FBC 20
Master Permit No..� q 4-1-7_S %
1 Sub Permit No. zk\j ( 8 — S6
REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: (` �� fiI (11,S i i�� �'f
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#: �� — ' ba&
Address: �� r OLfV Si2'i3Y� 9� �7
City: State: t`L Zip: 7�
Tenant/Lessee Name:
Email:
ne#:
CONTRACTOR: Company Name: Jrn (9�it'y j7�(.(�,�t.�l , 'L Phone#: jg — jo ' y�jq S�
Address: ( K% K-)
City: cac_ori_� Cj1tState: ram_ Zip:
Qualifier Name: Iouc_ '-`✓/"-) Phone#: �S� ��0
State Certification or Registration #: GJ Lao G Certificate of Competency #:
DESIGNER: rchitect/E gineer: � iO.A A 1 �,t"iL L J�LeaLj ::& ,�' ®Phone#:
Address: /mac q- City: IM/AE I S/ SState: Zip: 3 3130
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
S t &0 ; O We V�, a, D �5'i � � I
Specify color of color thru tile:
Submittal Fee $ ... _. _.> Permit Fee $ �s CCF $ CO/CC $
Scanning Fee $ iS ' w Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $ 80•
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 17A O • M
(Revised02/24/2014)
Bonding Company's Name (if applicable)
e \ ,I
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 not be approved and a rein tion fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of yA"� 20 ) by day of 20 by
RAN I who is personally known to �N K-I�-STf who is personally known to
me or who has produced p7L. h • L. , as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: �vY✓� Sign: 00"040� &41&
Print: Print: t E C,"CHASE CAM
P�� L�
Seal: ?+�*s: MY COMMISSION# FF 200055 Seal: �+a`"' CHASE CAMPBELL
r` EXPIRES: February 17, 2019 MY COMMISSION N FF 200055
Rt Bonded Thm Notary P abfic Undewbrs ?= EXPIRES: February 17, 2018
Bonded Thru Notary Pu* Underviters
APPROVED BY ` / Plans Examiner Zoning
f 4
Structural Review Clerk
(Revised02/24/2014)
R�v 19 -5(O
Aff mwmg_�.