EL-17-1729 (3)Miami 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 06 ELECTRIC ❑ ROOFING
Master Permit No
JUL 0 5 2017
Sfih
FBC 2011
P,G )1- 1-7z�
Sub Permit No.
❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 5 0oOF L v 2 Z
City: Miami Shores ►j County: Miami Dade Zip:
`— 33�
Folio/Parcel#: 3G-��(0— 0 6 Y OQ D Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): A 14- i gftQft Phone#: 51 (4r"' EiA —�.5
Address.'5Vt;' Nfla ( D3
City: State: O Zip: 3-�?[ 32
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: �� y �?v! ✓ G Phone#: ✓�� ` �(p i' G G O a
Address: PIO vO � w
City: Y v Vh / State: 1.
Qualifier Name: A14puto
State Certification or Registration M EV W d 0 0121
DESIGNER: Architect/Engineer:
_Zip: 3- 13715
ne#: 305 `7y� -04910
rtificate of Competency #: _
Phone#:
Address: City: State:
¢O
Value of Work for this Permit: S r Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace
Description of Work:
Specify colorofcolor thru tile:
Submittal Fee $ 3o Permit Fee $ 1-4 69i CCF $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
DBPR $
Zip:
❑ Demolition
CO/CC $ C�
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 13 - Q C)
(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. 'i
"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 cement s b ost at the job site
for the first inspection which occurs seven (7) days after the building permit is iss d. In posted notice, the
inspection will not be approved and a reinspection fee will be charged. A
Signature ��-- Sign
WNER or AGENT
The foregoing instrument was acknowledged before me this
QHA_ day of 20 by
Cih(fIJA who is personally known to
me or who has produced 5'4O 19)1 SG+ as
identification and who did take an oath.
NOTARY PUBLIC:
I
Sign: 11lij 00 td�r�
1�1 �•
The foregoing instrume t was acknowledged before me tis
day o 20� by
who is personally known to
me or who has produced as
identification and who id take an oath.
NOTARY PI
Sign:
Print: ' ¢F YNMtQSERFMW,4
MY UUMMI�51UN # FF 070735
Seal: - EXPIRES: December 10, 2017
pf F�? Bonded Thru Notary Public Underwriters
************************************************************************************************************
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)