FW-17-2292 (2)20e
Miami Shores Village
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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
Erg 2 5 2017
FBC20 )-I
Master Permit No. T W (I -2_ - Z
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ZPSO N/` /Dq?!� a:
Zi
Folio/Parcel#: Is the Building Historically Designated: Yes NO _
Occupancy Type: Load: Construction Type:Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Phone#: ��'. '1 J'
Address: 191 D All /0gH1 .<r air 46, i/..
City: A l ift State:
Tenant/Lessee Name:
Email
a
CONTRACTOR:: Company Name: &/ eal 4122AXT Phone#: - v �! -70
Address: 1 O_� 74 L(i / L,
City:
Qualifier Name:
r_tl Zip: v 541
one#:
/�OX70 t�
State Certification or Registration #: � L� Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:
Value of Work for this Permit: $
Type of Work: ❑ Addition
Description of Work:
e�-) : Gc)
❑ Alteration
Specify color of color thru tile:
Submittal Fee $ !so ` 6c) Permit Fee $
Scanning Fee $
Radon Fee $
City: State: Zip:
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace ❑,&molition
Technology Fee $ Training/Education Fee $
Structural Reviews $
i •
CCF $ "` —CO/cc $-''
DBPR $
Notary $ S
Double Fee $
Bond $
(Revised02/24/2014)
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
Zip
City State Zi
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
property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
or -the first inspection which occurs seven (7) days after the building permit is issed. In the abse� of such posted notice, the
ow
,w-ho§e
hspection will not be approved and a rein5pection fee will be charged. / J
Signature
OWNER/',br AGENT
The foregoing instrument was acknowledged before me this
day of -�A,$41&7'JA6 -20 17 by
S2j� D/'ZT� wh ersonally know to
me or who has produced as
identification and who did take an oath.
Signatu
The foregoing
instrumerif was acknowledged before me this
--01 nday of.����'1 20 t---N by
�` who is personally known to
me or who has produced \, " el U;� as
identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: o*t 11 t . T o! Sign: '
Print:
Seal:r �;;�. JOSEA.LOSA,SR. Seal: wY ` r x
�;,�: �•. ,� u Notary Public State of Florida
.: M' coMMISMN ncG 09set2 :° i� Sindia Alvarez q
EXPIRES: August 19, 2021 `5' �a My Commission FF 156750
'...: ..&xMled Tfru NO!Nly Pubflf, Ur►f9wher, %OF;`1 Expires10312 ASS�-
f
01
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9�7r# ########################
APPROVED BY ! Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)