PL-17-2176BUILDING
PERMIT APPLICATION
Miami Shores Village..:LCL i vE1)
Building Department AUo A,9 o»
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 11
Master Permit No. ((PL 17 — oZ � I —1
'(0
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION QRENEWAL
❑PLUMBING []MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 87 NE 92 Street
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:11-3206-013-0290 Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Bernadette Lopez Phone#:
Address: 87 NE 92 Street
City: Miami Shores State: FL Zip: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Mr. Cis PlumQvabT7Phone#: 305-651-7859
Address: 19932 NW 2 Avenue
City: Miami State: FL Zip: 33169
Qualifier Name: Kemble Ettrick Phone#: 305-651-7859
State Certification or Registration #: SR061536 Certificate of Competency #:
DESIGNER: Architect/Engineer: NA Phone#:
Address: City: State:
Value of Work for this Permit: $ Square/Linear Footage of Work. 615
Zip:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work. Permit Renewal application
Specify color of color thru tile:
Submittal Fee $ 0 - Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ 3 DBPR $ T • Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
Double Fee $
Bond $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable) NA
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. 1 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 Signature
OWNER or A 4w CONTRACTOR
The foregoing instrument was acknowledged before me this
The foregoing instrume�t�was acknowledged before me this
day of 20 by
/ day of vc.K � 20 /7 by
{ c�c.•� !�. fL7i IL'y— oM�Msoonanlly known to
CM�IG r who is personally known to
� C u `
a
me or who has produced VI as
me or who has produced as
identification and who did take an oath.
identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
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Sign:
Sign:
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Print: N
Print: f7 / �,
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Seal: _ * : 5q�60 . ctr
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+l"" DONALD MARTIN
Seal: =� `,
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pFF P.,
i�'Q •. Bonded���eAP,
MY COMMISSION # GG102743
Vol a
o,, EXPIRES May 09, 2021
PUBLIC, S�' 01,
"Nml+
APPROVED BY 0 -l' Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)