PLC-18-991BUILDING
PERMIT APPLICATION
Miami Shores Village C
Building Department—JR j13 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 8
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
FBC 201 .:� 1��
Master Permit No. ?U1 i - C ! 9 )
Sub Permit No.
r-jBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION MRENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: /
❑ CANCELLATION ❑ SHOP
DRAW
Folio/Parcel#: it " 22-zi'd53' 00N Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: I Flood Zone: BFE: FFE: �p
OWNER: Name (Fee Simple Titleholder):��r �%/1 �%Q Phone��,C,�
Addr ss: ' / t.0
City: State: zip:�Ja
Tenant/Lessee Name: Phone#:
EmailAn.110X-F- 1 /Daol. i -ont _ SOLft ro
CONTRACTOR: Compa�Y Name: �/ �� �1(,SQ Phone#1L
Add /-11_M 11._.., -1. ._. — \\
City;
Qua
State Certification or Registration #('R, N2W2y Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#: _
Address: City: State:
Value of Work for this Permit: $ Square/Linear Footagpof Work: _
Type of Work: ❑ A iticn [:1 Alteration 1:1 New Repair/Re lace
Description of Work: T l'�.IL 4",n&- 4 t32 &k-ak- � (l(.0��
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $ _
(Revised02/24/2014)
�'■ a'�' "Woof Ai1`1
I
CCF $_
DBPR $
Zip:
❑ Demolition
I—, - 1j.
CO/CC $
Notary $
Double Fee $
Bond $ S
TOTAL FEE NOW DUE $ �1
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 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.
WSignature �' Signature
OWNER or AGENT CONTRACTOR
Thegoing instru s acknPwledged beforf this The forgoing instrument was acknowledged before me this
day o I I 20 1 V , by 1_ day of 2012 by
t3Ge,- Ci w di patrsonally kn wn to` _ X t i err hi1'lCitfti:& , who is personally known to
me or who has produced V V 1 U ame or who has produced a as
identification and who did take an oath. identification and who did take an oath.
NOTARY P LIC: NOTARY PUBLIC:
Sign: Si on
PrintPri Q1) !
Seal: ,�,,%Y PUe�� NANCY GOLDRING
Seal: � •.••••,
* * MY COMMISSION # GG 059069 Notary Public State of Florida
N. o= EXPIRES: February 15, 2021 f Katherine Santos Santana
�o My Commission GG 171812
9TFCF F`oP� Bonded Thru Budget Notary Services Of Expires 01/01/2022
############################################################### # # # ## # #### ###########
APPROVED BY �r Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)