REV-17-986 (2)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
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�FBnC 2/0 (14
BUILDING Master Permit No. `� qz�
PERMIT APPLICATION Sub Permit No. ?:Ex)
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❑BUILDING ❑ ELECTRIC ❑ ROOFING V REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS: 6-15 691'r4C 7 LV H CD (/ ✓'Se
City: Miami Shores County: Miami Dade Zip: 7 3
Folio/Parcel#: I f -- S ZO & - of 7 — Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �r ►v�..� 4 GI �(%� Phone#: �lS� �F9 �/ — �% g% f
Address: -!5' k S
k0 r�s State:
Tenant/Lessee Name:
Email
C
ne#:
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CONTRACTOR: Company Name: Si�-m11��• +Phone#: Ot— 410 O 6 �fa�
Address: '-'Y 4 O 3 C1 A V M
City: ce C k- Stater Z
Qualifier Name: C. te- C— IM ` S �y Phone#:
State Certification egistration #: 4 Q C - Efl {p O S� Certificate of Competency #: _
DESIGNE . Architect/ gineer: ► r Arl'L1� l� �1 IP6 C L L Phone#: �o S
Address: 3 nAf Z S"F 1" I� City: t"M/er-ti l 5 %ff3State: F�— Zip: 5' 3 3
Value of Work for this Permit: $
Type of Work: ❑ Addition ❑ Alteration
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace
Description of Work: UIN 1 LFJ F-t-- C-1c
} O 4e �6
P�
❑ Demolition
Specify color of..,c6llo`rthru tile:
Submittal Fee $ Permit Feef$' �S CCF $ CO/CC $
Scanning Fee $ (Z- Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $ 1 2
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(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.
"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 nspection fee will be charged.
Signature Signature
E
r, OWNER or AGENT CONTRACTOR
:,
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
Z-7 day of 20 �� by , Z7 day of, f b- Ir-L--- 20 *7 ,by
who is personally known to ' C�1Lv— \ Id�@ LsR�—wvho is personally known to
me or who whhoo has produced V- �• as me or who has produced ' C as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUB
Sign: G' Sign: r.
Print: `✓0, - 7 Print: ���/4 ��l Ve
Seal:
*0 Put,LAURA F
�' : �P * MY CSeal:
MMISSIFF IW7O' LAURAFARLEY
"*1 EXPIRES: March 16, 2019 * * My COMMISSION # FF 18M
Bonded Thru Budget Notary Servim EXPIRES: March 162019
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)