ACT-12-467-3/ A A I I �Z -V4t-.j 1P
BUILDING
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
PE ICATION
FBC��
Permit ype: BUILDING _ROOROOFING
OWNER: Name (Fee Simple Titleholld�er):_, IEA /t/I E1 � �
Address: � & -7 P .0 ' . "l 1 -<.-? - . /Zt;Ew C'
City: a ai l' 5601 C5 State: �-
Tenant/LesseeName: �/�j - `-TF' _%
Email: _rko2-7 %Idgi2 LZDI�IL4 5f- /7e ,
JOB ADDRESS: q/,-7 V,55-
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kA' R 1 U L' 12 �J
BY: -----
Permit No. v ► �`
Master Permit N
*192 Phone#:
i
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 113 oW % 00 3on sn
Is the Building Historically Designated: Yes NO Flood Zone: , V
CONTRACTOR: Company Name: / C3' O AVt Phone#: 'P5 vZ (v I
Address: f 3 a ��j -5,W 7 677
City:
7—
City: M �l9 �YJ / State: Zip: -3<3 j J
Qualifier Name: ✓i` ✓� to Phone#: '-_30.- ;7-
State
2State Certification or Registration #: ertificate off Competency #:
Contact Phone#: --re-f- y,.-' 2Qn s: g4-1,'0_/+ de Qil,_110 /s o�` �j/t j %• Corte
DESIGNER: Architect/Engineer: - — Phone#:
404V AV
Value of Work for this Permit: $ ,e:7e Square/Linear Footage of Work:
Type of Work: ❑Addition DAlteration AdNew ORepair/Replace ❑Demolition
Description of Work:
Submittal Fee $ Q_ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ / Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
ouble F Structural Review $
Technology Fee $
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
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 rst inspection which occurs seven 'days after the building permit is issued. In the absence of such posted notice, the
inspe on will not be approved and a rein ection fee will be charged.
Signatur Signature CMTS
finer or Agent Contractor
The k n instrument c owledged fore me 's � The foregoing instrument was acknowledged before me this
day of , 20 �L,.b ay of IG , 20 j,�, by Dav(J a o r r� /
w o ' perso a}lllyy known t(o'�me who has produced who is personally known to me or who has produced �lo r (J a.
—0 I V " I ' AQ&cation and who did take an oath. r i W r . i Cn 11 SlL as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
*****************
APPROVED BY
NOTARY PUBLIC:
0
s
f, `P�,
UC SeV S�0 Sign:
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N° M � a Y PS .�
kq G°mm gine a\N Print: JO�'1i0. rA 9�::;Missiov •.Cp�
* " ailed �0U4� My Commission Expires: ;,0 VJ ��'�+'%� Z
cfgc 80 _ NOTAR ?�'t
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PUBLIC
539 ' `QP`:
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Plans Examiner �7.?7 �i qRkeFL��
Structural Review
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Clerk