PL-18-864Miami 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
❑ BUILDING ❑ ELECTRIC ❑ ROOFING
r 4 v E1)
OCT 0 lfI
FBC 20
Master Permit No. t_?p 11 1
Sub Permit No. PL I
❑ REVISION ❑ EXTENSION [:]RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):%,9/%ly/���Q Sir t//�—s Phone#: SDS ' 7��• 97`
Address: 1,9 -,VL! 0-fS7-_
City: "1�/n A-7' �f�d/tC.S State: 101r1c...O4 Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Coo ppany Name: / /rd'`J Phone#:
Address: AW—'
City: f7�//q G��/���---�
Qualifier Name: li'7i�/L/d
State Certification or Registration #: G�
Zip:
»� Phone#:
�Z0 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State:
Value of Work for this Permit: $ o 0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of Work:m
Zip:
❑ Demolition
V:r...... ......� • ,.,�,. M.
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ -. co/ccC $`
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
Zip
City State 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 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 a and a reinspection fee will be charged.
Signatur Signature ..
OWNER or AGENT CONTRAC
The foregoing instrument was acknowledged bef re me this
day of (�Q '20 by
CV'7:!ANho is personally known to
me or who has produced �L--- as
identification and who did take an oath.
NOTARY PUBLIC:
APPROVED BY
(Revised02/24/2014)
The foregoing instrument was acknowledged before me this
3'' day of I
"'0&obty 20 IS
CiCi► O �, V;p;4fJ who is personally known to
me or who has produced — Il'ty`w ICS-�A1SICS-�liSf as
identificatiotanll vho.diO;AkeA,n oath.
NOT R
Sign._
Pri nt:
Seal:
**************************************
Plans Examiner
Structural Review
a
YANADY PRIEFO
MY COMMISSION # FF 214531
EXPIRES: March 25, 2019
Bonded Ttru Notary Pubac Underwriters
Zoning
Clerk
Miami shores Village
\%. Building Department
UP, 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N. � S/71v�71 �hlb_$6T
Owner's Name (Fee Simple Title Holder).J--,-O l///dW S�7%/t/-s Phone #: ZZ, - 10- %YgS
Owner's Address: /46o Al/�-1-
City: iii f,&y, - 5S40xzs State Zip Code: -3J/-7Lf
fob Address (Of where work is being done): //7/40N� 111,9-1
City: Miami Shores State:—Florida Zip Code:
Contractor's Company Name:
Address: z
City: /rte -.tom
Qualifier's Name:
Architect/ Engineer of Record Name:
Address:
City:
Describe Work:
State:
Z�- Phone #: .3.ig S 338 2 -
Zip Code:
Lic. Number:
Phone
Zip Code:
hereby certify that the work has been abandoned and/or the contractor/architect
is unable or unwil!jAg to complete the contract. I hold the Buij4ing Official and the
i Shores harmless of all legal i
S
The fo oing instrument was aknowledged before mee,, /
this day of Com-- ,2d2,by����t
Signature
Who is personally known to me or who has produced
as indentification.
Nota u ' .
Sign:
// Cbfitra or or Architect
The foregoing lnstru t was aknowled before me
this day o , 20� y 1
who is personally known to me or who has produced
as indentification.
Seal: Seal: 04AJWME MIGUEZ
off•.,•
cK AINE MIGUEZ `+S W coMttuliwm # GG 1176551
MY COMMISSION # GG 176551 11, 2022
p(PIRES: January 17, 2022 w EXPIRES January
Imoo, •!;si;4�'9ordodThu PubNcUndenrtiu
BoadedT Uncle w leis