DS-18-194e
Miami Shores Village
X V.
BUILDING
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
FtSL cu 14
Master Permit No. ( C':3 J �7
PERMIT APPLICATION
�UILDING ❑ ELECTRIC ❑ ROOFING
Sub Permit No
❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL F-] PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
Email: 6X \L,5Lk5 K- u e 00 9rvw':•-k .
CONTRACTOR: Company Name: Phone#:
Address:
City:
Qualifier Name:
State Certification or Registrati
I
DESIGNER: Architect/Engineer:
'•i
of Competency #:
hone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:)
Type of Work: ❑ Addition E Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ � ' C7(:> Permit Fee $ EO - Cc-) CCF $ 0 ` �� CO/CC $
Scanning Fee $ Radon Fee $ 2 2 DBPR $2 ' Notary $ S•
Technology Fee $ 0 ' Training/Education Fee $ (0-20 Double Fee $ ,
Structural Reviews $ Bond $ S0
TOTAL FEE NOW DUE $ 161--7 • g 5
(Revised02/24/2014)
CONTRACTOR
DRAWINGS
JOBADDRESS: 1!5z) ,1/&-.)
1
City: Miami Shores
County:
Miami Dade
Zip:
Folio/Parcel#: kk —31 b k —t>
00 3 k
Is the Building Historically Designated: Yes NO
Occupancy Type: /ti Load:
Construction Type: CR Flood Zone:
X BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): y14'- �
✓eyl`z
Phone#:
Address: 1 56 �JO I TV-
s1'"
City:
State:
YC -40^
Zip: 33ES�
Tenant/Lessee Name:
Phone#:
Email: 6X \L,5Lk5 K- u e 00 9rvw':•-k .
CONTRACTOR: Company Name: Phone#:
Address:
City:
Qualifier Name:
State Certification or Registrati
I
DESIGNER: Architect/Engineer:
'•i
of Competency #:
hone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:)
Type of Work: ❑ Addition E Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ � ' C7(:> Permit Fee $ EO - Cc-) CCF $ 0 ` �� CO/CC $
Scanning Fee $ Radon Fee $ 2 2 DBPR $2 ' Notary $ S•
Technology Fee $ 0 ' Training/Education Fee $ (0-20 Double Fee $ ,
Structural Reviews $ Bond $ S0
TOTAL FEE NOW DUE $ 161--7 • g 5
(Revised02/24/2014)
♦A
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 a reinspection fee will be charged.
Signature A Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
23 day of20 I by
�
VI �l2 M1jC_ �SUS LE Uo is rsonally known to
me or who has produced Z-�ptVW— N�as
identification and who did take an oath.
NOTARY PUBLIC:
-e,w
Print:
p: " S:!1dia Alvarez
Seal: w n� aty Commission FF 156750
oFEto� Expires 09103/2018
APPROVED BY
(Revised02/24/2014)
The foregoing instrument was acknowledged before me this
day of 20. by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
{ Seal:
4.
{
as
Plans Examiner Zoning
Structural Review
Clerk