DS-16-1866Miami Shores Village
W' J L 0 5 2016
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138:
Tel: (305) 795-2204 Fax: (305) 756-8972 -'
I -r Li
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 ( y
BUILDING Master Permit No. -DS ( b— I P6>
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1-ISC me /00*1
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: ) I o(o 613 0350 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple
,T,i/tleehholder): 11)0 C)[�k 1rc h (-A- Phone#:
Address:'' AyL%
City: rl I a w] I SVIL& S L� State: Zip:
Tenant/Lessee Name: a , `Z Phone#:
Email:
CONTRACTOR: Company Name: L.pi(iC Il (1Sh'
L✓!UCf jr Yj Phone#: 954 x(f6' (3)
Address: AS -11 iii Si-elGC � -! -#l,br) _ _'4 IN
City: ca .CI) LA c j ,P eL State:
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
V
111 Phone#:
icate of Competency #: _
Phone#:
Address: City: State:
Value of Work for this Permit: $ / O (*) . C) n Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of Work:
Specify color of color thru tile:
p: 3307" a
Zip:
❑ Demolition
Submittal Fee $ SO Permit Fee $ 2s• CCF $ 3 CO/CC $
Scanning Fee $ Radon Fee $ 2 • GO DBPR $ 2 • ()o Notary $
Technology Fee $ . 03 Training/Education Fee $ ( GO Double Fee $ //n®
Structural Reviews $ Bond $ �U
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
Zip
State 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatureffl Signature
OWNER or AG T CONTRACTOR
The foregoing instrument was acknowledged before me this
S_�_ day of 20 So , by
The foregoing instrument was acknowledged before me this
i s4 day of ,M� 201C by
J SP C�r�Z, who is personally known to jA1[6C1 o L=:CtC0Cfr_ who is personally known to
me or who has produced V -L ►bn efs u--et-6C as
identification and who
. Y KYLE C HAM13RICK
NOTARY PUBLIC: ='° MY COMMISSION # EE867056
.2 • • EXPIRES January 22.2017
osf�,•
4 9a-0153 FlondaNaiarySeNbe mm
Sign:
Print: /G,// ,ii[tMhrl[l(_
me or who has produced lq-'- [�rtc wr--, C.cceA Pe as
identification and who d'
KYLE C HAMBRICK
NOTARY PUBLIC:
My COMMISSION # C- 867056
'a "* EXPIRES ,January 22. 2017
183 FloridaNcnarySe-1- com
Sign:
Print: "te gl4(lpr�c/_
Seal: Seal:
APPROVED BY v Plans Examiner [/ Zoning
Structural Review Clerk
(Revised02/24/20141
BUILDING
PERMIT APPLICATION
Miami Shores Village
EIVED
Building Department JAI 23 2019
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 By•
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 s _
FBC 20 1
Master Permit No.�J— 7— 1(0— 1$(0(o
Sub Permit No.
F --]BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
F --]'PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: _422 NIE Itz nk
City: Miami Shores County: Miami Dade Zip: X313 g
Folio/Parcel#: 11-3ZCKoU1-I Q3gp Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder) -.—W- Oe 1% y 6%=(,jj Phone#( � ��1 1 ZA
Address: �10 PIZ 100 S+
City: M laws f 5ttes State: Rox4 o6 Zip: 33138
Tenant/Lessee Name:
Email:
one#:
CONTRACTOR: Company Name: le—[Qcy- fF�-7Y UL��1'l� Phone#: q"l 2 71
Address: (OY-14 N SiMA?_2'0�2j . -1 * 1(00
City: LnGrpni.A C-rCe-IG State: (7iny2tog Zip: 33\73
Qualifier Name: N IChae..I )e Iqc y Phone#: LgS-1 ') Zfo3 ?) Z.0
State Certification or Registration #: C G -IC 1 S•1 gQg8' Certificate of Competency #:
DESIGNER: Architect/Engineer: N�fi Phone#:
Address: 1 fi City: State: Zip:
Value of Work for this Permit: $
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:.
Submittal Fee $ "" `" "� ''w "Permit Fee $`
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
CCF $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $
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 � , 1. 1 1 / State
Zip
Zip
r
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
r
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. , r � _ ,I.
_.l .. _ . a ,t . !
a � I
Signature Signature
OWNER or AGENT 1 CONTRACTOR
4 i T
The foregoing instrument was acknowledged before me this ° ` The foregoing instrument was acknowledged before me'this
day of , 20 , by 11 day of 5:JnL kQ2 20 19 by
who is personally known to I`11C.MNC�1e1 who is personally known to
me or who has produced as me or who has produced PPCS[ 0a11V iC. )0j&t'1 as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign: /
Print: Print:
Seal: Seal: > 9 � Notary Pubbe Ste*of Florida
. , � Louis Gabriel Machado
4 y My Comm ssion GG 278150
Nap pfts 22
APPROVED BY
(Revised02/24/2014)
Plans Examiner
Structural Review
############################
Zoning
Clerk
Lelack Construction
6574 N State Rd. 7 #160 Info lelack.com GCG1514048
Coconut Creek, FL Licensed and Insured 954-263-7120
January 22, 2019
Miami Shores Village Building Department
10050 NE 2"d Avenue
Miami Shores, FL 33138
RE: DS -7-16-1866
To Whom It May Concern,
Please accept this letter as a request to cancel permit DS -7-16-1866. Work order was cancelled and
never initiated.
Best Regards,
'--��M`ichael Lelack
Le Lack Construction