REV-19-1229a
i?�l�i-122
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Miami Shores Village
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
BUILDING
PERMIT APPLICATION
F-] BUILDING ❑ ELECTRIC ❑ ROOFING
F-IPLUMBING MECHANICAL [:]PUBLICWORKS
JOB ADDRESS:
Folio/Parcel#: % 12- l 3 6
I JE 101 [
�A-�
FBC 2011
Master Permit No.
Sub Permit No. pF-\j05 -19
" 1229
NI"REVISION ❑ EXTENSION ERENEWAL
CHANGE OF CANCELLATION [:] SHOP
CONTRACTOR DRAWINGS
3 I C=
the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder 0,C4 I,:I.QIL WtrL-Ir-
Address: 29 NF— It 0)9
City: ' y l ! Q V" , State
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address: c'if3t7 — �
City: --43
Qualifier Name:
97--6owt:A c -t ZiD: 5 31 6
hone#:
6 `Phone#: 3vC-- '41t - 6. 26
'l I Zip: 75 Ole.
hone#: 4 -et. - �-: 1 2. v a1F6 -
State Certification or Registration #: Certificate of Competency M
DESIGNER: Architect/Engineer:
hone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑Demolition
t� _ t— rtQR, lz, ti
Description of Work:
NAO Ca
t Yr'! ,lr rAi i
1 t
Specify color of color'thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR•$• Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
Double Fee $
Bond $
TOTAL FEE NOW DUE $ �� W
O
TIP
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 psermit`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, 6 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 grrd-N reinspection fee will be charged. 1 n . ,
-N-- Signature t
OWNER orGENT � C NTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of (40—t
a 20by day of 20 by
C(7l;UJ Vr- Illw-?-who is personally known toot who is personally known to
me or who has produced tL-bo�- Lf --t,- me or who has produced %32y`,i,n✓ZC�JGe✓y hoa:,l as
identification and who did take an oath.
NOTARY P LIC:
Si
Print: l IAiA�I�
Seal:
*****************
APPROVED BY
(Revised02/24/2014)
SINDIA ALVAREZ
MY COMMISSION # GG 238273
cvoiPrq- Santember 3.2022
identification and who did take art oath.
NOTARY PUBLIC:
Print: Q
Seal:
r--'eXPIRESSAp
COMMISION# GG09; ril 10, 2021
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Plans Examiner Zoning
Structural Review Clerk