REV-19-1228Miami Shores Village R������
Building Department MAY 29a�
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 r
FBC 201 70
BUILDING Master Permit No. Kms_ °' _1TZ-FI"'.t _
PERMIT APPLICATION Sub Permit No. V —) C
❑BUILDING 21'ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
AXIBING ❑ MECHANICAL E] PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: Q,Gj ` N �- LO 0( 5�-re l
City: Miami Shores
'� County: Miami Dade Zip: 3 31
Folio/Parcel#: I j a1 3lp Q0 "0 6 0 0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFEt: ` FFE:
OWNER: Name (Fee Simple Titleholder): Jaciquix "�, �yU1Z_L L Phone#:
Address: 20, fit! Io
City: m, a —%+ -5tv-s^@ 5 State: ft Zip: 334
Tenant/Lessee Name: Phone#:
Email:&�:OQ
CONTRACTOR: Company Name_: �"' �e&V,(G Phone#:
Address: —7 ) IE 1qs}31aA 15+0clelt
City: 111G.{C0.l\ State: r��q Zip: 33013
Qualifier Name: ILA 15 M. A j u ( la Phone#: b FQ 95 3 " 2$03
State Certification or Registration #: EC L 3002055 Certificate of Competency #: }
DESIGNER: Architect/Engineer:. Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 1500 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work:
�� O d w� a wa•� �rcc �a
Specify color of colorthru'tile:.
Submittal Fee $ Permit Fee -$ CCF $ CO/CC $
Scanning Fee $ Radon -Fee,$ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ !43 C!)
(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
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. , s
"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." + I
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 tachment� certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) ys after the building permit is issued. In the absence of such posted notice, the
inspection wil of be rove and a ' inspectio fee will be charged.
Signatu
—! OWR or AGENT
The foregoing instrument Is acknowledge before me this
day of 14zy-
known
�J by
to
me or who has producedC4,--� as
identification and who did take an oath.
Signature
The foregoing insJument was acknowledged before me this
..l
day of l ck,4 20 I by
,
+v er,oo,v.e&0-QA4 k(KocpKwho is personally known to
me or who has produced In.ld c S �o lcL as
identification and who did take an
NOTARY PUBLIC:
NOTARY PUBLIC:
ltltll111/
ERA
•
Sign:
•�gS�O Xpi9 ..0: Sign:
Print: ` x
:) Print: wt L
Seal:.•
�FF9�.;L4� Seal:
i�yo. • Nolary ?0����� '�Pr:'s JACQUELINE GONZALEZ
•
jgYP��� ��` MY COMMISSION p GG092580
*:::,r'lINPRUBLIG MSL
APPROVED BY
I Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)