REV-19-1840t
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ell
Miami Shores Village
Building Department aU�QB
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 10%�
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC (20
BUILDINGaNU
e it NO.PERMIT APPLICATFRkIf1^1emit No. R�wag—'��
❑ FIN
BUILDING j�ELECTRIC ❑ ROOG '___ �'R XTENSION [—]RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION [--]SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: U1 NlE�-�--
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): FY'1 Wna Phone#: JSQ Q (o �2 3 l 13
Address:
City
State:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:TVl ���'il��v-�_ Phone#:
Address: 3WSIA � , C:j /I
City: 1 �-`- ply State: EL Zip: 3�Oa3
Qualifier Name: Mlcic) nmsn Phone#:
State Certification or Registration #: Certificate of Competency #: 1 360 (D (19,
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ -750-00 Square/linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace d ❑ Demolition
Description of -Work: SQ -QT n - ftlV(S1 OAS. PaMe.i LAW MQU.,W �I V1� SDIij
Specify color of 616H ru file::.
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ _ DBPR $ Notary $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Training/Education Fee $
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
City
Zip
.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 approved and a reinspection fee will be charged.
Signature & .! 4LU �.�
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of 20 by
11— 1�4(,f O who is pe Wally n wn to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
as
Signatur
CONTRACTOR
a r
The foregoing instrument was acknowledged before come this
—�-� day of 31 &+20 1 I by
JUII �4 i\ S who is personally known to
me or who has produced D6W-AS `t CD T&._ as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: l Z✓L� ,,�t�•:s Signer/ 1_
Print: P•_ �2�j� ��' Print:/
LU ! ° : Z. Notary PuDIK State of Floride
Seal: : *= Seal: Nathalie C
i • ��� 0� 9 Ole`T� � My Commiss252087
i .O/SSIWwa ��� w Expires 12119E/2022
APPROVED B �Plans Examiner
Structural Review
(Revised02/24/2014)
Zoning
Clerk