RF-15-2401Miami 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: (30S) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC [g/ROOFING
P,F,cIF,r7ED
SEP gr 2 203
BY:
FBC 20/y soh.
Master Permit No.
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I z 3 d N15 IC)-Zh J A - v e
City: Miami Shores County: Miami Dade Zip: 131 15 &
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: ` /Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fete Simple Titleholder): W Q A 6 ra wJ OO l 1p6 RK Phone#: 30 S 7-6-q- 44-,30Address: j � �t> Wff IeiZ "d /WJE
City: 5 `+c> re j State: L- Zip: -S3139
Tenant/Lessee Name: A Phone#:
Email:
CONTRACTOR: Company Name: 5
Address: t L i 1315 FA- 5$re'e-�
City: (rtev4,✓ ( State:
Qualifier Name:
5 TMJ LT K:. .J
J VJ~t1rU��
State Certification or Registration #: CC C 1, 3 Z 7 5 8 I Certificate of Com etency #:
DESIGNER: Architect/Engineer:
abs" 5Z7 9 36 3
3,315
Address: City: I State: Zip:
Value of Work for this Permit: $ 2� C f Square/Linear Footage offork:5-f--
Type of Work: ❑ Addition ((��❑ {{��Alteratio`n ,❑ New M] Repair/Replace ❑ Demolition
Description of Work: ke-- 1-csoT tri- R02- 9Q- c.
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Permit Fee $ CCF $_
Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CO/CC $
Notary $
Double Fee $
Bond$ r _5r,ITD)
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable) 1 JA -
Bonding
A -
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
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 n�beproved and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
�
a 5 day of $�.//TG{�'1 &C-/- , 20 �$ by
who i Ily know o
me or who has produced
identification
NOTARY
an oath.
FDIC T PrrTS
#EE169W
y 14, 2016
The foregoing instrument was acknowledged before me this
i St" day of / GP+ev"� 6e�. 20 , by
�Gf�G�C �r.i�s�✓� who is ersonally kno o
as me or who has produced
identification and who di
nri
NOTARY PUBLIC:
`?
Print: �r� / 7 Print:
Seal: Seal:
sssssssssssssssssss
APPROVED BY _ _ T (I' -1 Plans Examiner
Structural Review
(Revised02/24/2014)
as
take an oath.
,CM -MISSION #EE169667
Fearuaiy 14, 2016
sssssssssssssssssssssssssss
Zoning
Clerk