REV-17-2648 (2)r
Miami Shores Village
BUILDING
PERMIT APPLICATION
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 ❑ ELECTRIC ❑ ROOFING
M,M —
sjvED
NUS` 06 ;;17
FBC 20Lq
Master Permit No. )Z(, 4- 3
Sub Permit No. i—t—
N E 2Ceu�
g] REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING WfMECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ' ?N w I e ft, > 1 -
City: Miami Shores i County: Miami Dade Zip:
I J�
Folio/Parcel#: I - 1 C 1y2 S - C I QC Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): t t ( -Fn CZ 17 1 Phone#: - l I `J
Address: �-2 I K, wy (o
City: n' 1 L-1 r)1 I 5 �Av r"eS State: l Zip: 331 SLR
v� _
Tenant/Lessee Name: Phone#: �c, -� 9 7` 34
Email: CONTRAC_TOnnR: Company U Name: M l75 ; Phone#:
�Address: 2/
s"/ l �j G✓�L /T4`�
City: / JfEv+ State: �L Zip: 331 E
Qualifier Name: /cis^�' J /�ua�� y Phone#:
State Certification or Registration #: G M G 12 S �� Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: .�City: State: Zip:
[_.��,)
Value of Work for this Permit: $ � If Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: N�'� TLC i" r ✓ ""'y` , �^ �xsf.'� '=i��r; ��. /1'fJs f �••� �i� ��
Specify color of color thru tile: _
Submittal Fee $ Permit Fee $ IOU CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $ n-
TOTAL FEE NOW DUE $ 3y
(Revised02/24/2014)
— • .<
Bonding Company's Name (if applicable)
Boi,ding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
ME
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 reinspection fee will be charged. . _ /)
Signature -- Signature "
O NER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
c�d'a�y of (�C����`�j✓� 20 by day of � , i� 20 ( i by
-1-��,��� who is personally known to who is personally known to
!�
me or who has produced'1 �- t_ 1(-' -)2SF3 s me or who has produced r— U-E-ez L as
identification and who did take an oath. `�X� �2l`identification and wh did take an oath.
NOTA IC: NOTARY PUBLIC:
Sign: Sign. --
Print:U,� ��1` -�i�1 Print: i2
t'�r r� pUQt " Notary Public State of Florida
Seal: o 4�
y MY C41MhWW EVk" Seal: Carlos Jose More G 712267
Mt>u� 02f
* 12.2
m %a P,d� Expiros 06/20/2021
"A'F or a CCer� NM GCS BINS
APPROVED BY "� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)