REV-19-1226\\1�\
\� Miami Shores Village RECEIVED
Building Department
MAY 29219
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 byl
INSPECTION LINE PHONE NUMBER: (305) 762-4949 l�
FBC 201
BUILDING Master Permit No. 1;? G 10 ' IS -30 (4
PERMIT APPLICATION Sub Permit No. Pk V—d5 - IC?
�UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
a LCONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: 33I 6'
Folio/Parcel#: ` 121 3 (PZ-')oLt Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 11t.'=9 L G, %V",z ft -LO Z --Phone#: -3t)6 a'b t ""Sy O1
Address: 2-41 Nz l0 °( ST
City: M; ow.d State: zF to r �� t Zip: ✓3 �G
Tenant/l,essee Name: Phone#:
Email:
CONTRACTOR: Company Name: F-11Jrr r -L -o �N)6fL_ Phone#:
Address:
City: State:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 50o ca Square/Linear Footage of Work: 4$ 5f
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: 1 I
Specify color of co or thru tile:
Submittal Fee $ 4��Permit Fee $ too, Ca
Scanning Fee $ 2--) . 00 Radon Fee $ 0 •y�
Technology Fee $ 2 • 50 Training/Education Fee $ _
Structural Reviews S
(Revised02/24/2014)
CCF $ b • GC CO/CC $
DBPR $ 2 Notary $ . Cly
Zt� Double Fee $ 91
Bond $ 59
TOTAL FEE NOW DUE $ ��� • •36
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. t ,
"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." a
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, o certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which ccurs seve days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approvednd a rei specti fee will be charged.
Si
OWNER or AGENT
The foregoing instrument was acknowledged before me this
7— day of (al -7 20 by
(CIO V, �ner'sonally known to
me or who has produced as
as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
MI
SIL
Signatu
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 by
, who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Si
Prini: ;
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Seal: #FFg54j6o Seal:
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APPROVED BY �" Plans Examiner. Zoning
Structural Review Clerk
(Revised02/24/2014)