PL-15-1994` Miami Shores Village -�-
Building Department AUG 1 22015
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
FBC 2(Yy s)*
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ty€ ?Z;,
Z
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: ' es NO
Occupancy Type: Load: Construction Type: Flood Zone: ftJ'd BFE: FFE:
OWNER: Name (Fee (e Simple Titleholder): 7k \ C_r-- CC9w�,ly Phone#:�78f--, 3Z.s-T—
9-;I
ee
Address: 9 I lJe- / 2
City: kt�c M i k S ttO-OLCm"�; State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Phone#: a�
Address: ,.=� SW 1-� )
City: Istwi (
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Add
Value of Work for this Permit: $
Type of Work: ❑ Addition
Description of Work:
Alteration
rtificate of Competency #:
City:
ne#:
State: Zip:
Square/Linear Footage of Work:
New ❑ Repair/Replace
❑ Demolition
Specify color of color t'hru tile:
Submittal Fee $ 5h'6 / Permit Fee $ 30ri �i� CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
DBPR $
Notary $
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
E
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 ust a posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In thea ence of uch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT ACTOR
The foregoing S�instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 1n� C---Jc- 20 by 6_ day of 2015 by
who is personally known to I' G w rso own to
me or who has produced ON as me or who has produced
``,y PY'•' SARIMA BATISTA
identification and who did take an oath. identification and w o id take a shat �.
:.- MY COMMISSION 4 EE 873354
NOTARY PUBLIC: NOTARY PUBLI `• EXPIRES: May 11, 2D17
�;p� �.. Bonded Thru Notary Public Underwriters
i
Sign. ,� Sign:
Print: F'\: Print: iLl Q
Seal: lySeal:
REBECA M.PASTMA
MY COMMISSION # EE872624
os
EXPIRES: February 07, 2017
APPROVED BY (�CY/s Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)