WS-17-134BUILDING
Miami Shores Village'
Building Department JAN 18 2017
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY'— - -
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20tkA
Master Permit No. VN'� �� 1—+–GQ
Q
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
Sub Permit No.
❑ REVISION ❑ EXTENSION RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 5'19 Grmd G.a7%C6lL(�Jp ? _
City: Miami Shores Countv: Miami Dade Zio: J3f39 /. _1
Folio/Parcel#: ll- j.�Q&- Ol %' /V/o Is the Building Historically Designated: Yes x
Occupancy Type: Load: Construction Ty e: Flood Zone: BFE: FFE: _
00
OWNER: Name(Fee Simple Titleholder): Q Phone#: O�o
./_ n
Address: '� i K t-7/'O.,rd ( D,1irowr
City: 41 i &M ! ,jh6re S
Tenant/Lessee Name:
State: )5--1 Zip: 331-39-11 _
Email:
CONTRACTOR: Company Name:, -a.U62et� i
Address:2-3o/ k 41/ �A -7-,err -.,4 X
City: 0M i State:
Qualifier Name:
State Certification or Registration #: _e"L_ Z
hone#:
hone#: -GLS
Zip:
Phone#:
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: V9 rr__ Q 5 Z City: State: Zip: r- _
Value of Work for this Permit: $ - I (00 - Square/Linear Footage of Work: --nV
1 S _
Type of Work: ❑ Addition ❑ Alteration ❑ New 0 Repair/Replace ❑ Demolition
Description of Work:
-I5 Z40<5
Specify color of color thru tile: _
Submittal Fee $ Permit Fee $
Scanning Fee $
CCF $ CO/CC $
Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Rev1sed02/24/2014)
Notary $
Double Fee $
Bond $ _
TOTAL FEE NOW DUE $ _ 2O
,
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.
Signatur
OWNER or ENT
The foregoing instrument was acknow a ged before me this
day of�) inu cs L2/ , 20 /7 by
/-+h oS S who is ersonally known to
has produced as
i on an ....... re`.�-•.
Ati1F ^A dNv„ry
T
{�I@ UBLICe `'o: Notary ,.;dq
tit w -
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fVly �_n✓n•'a h�� 0.2i0ii
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'' �:,t�►�, Sign•
Print:
ALICE ********
Plans Examiner Zoning
Nota'. Ja
C,
JyAiltl
APPROVED BY
(Revised02/24/2014)
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
/� day of 2nuDrfl 20 1 % by
Oc�!lCc2,f1�2C�t/ who is personally known to
or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
M. BRYANT
Seal: Mogry Pub110 -State of Florida
's �9mmbstton I FF 903612
My Comm. Expire; Nov 3, 2019
�"!�'�"' Bonded though National Notary Aepi.
Structural Review
Clerk