RF-18-851BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Te1: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
FBC 20 F�-
Master Permit No. `2—T (�) y8'�A
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [—]RENEWAL
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: �-N� ST
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): 1 LVM 1MA&RP-Fione#: _9)C)5 '&A `7' l;4v'g
Address:
� ' S Z� NZ
/yb`
City: S �Qmi- s State: Zip: l
Tenant/Lessee Name: Phone#:
Email: C—PtIif n6tL,• CAH.
CONTRACTOR: Company Name:
Address::12�2_15 w1 -
City: "\
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
EL Zip: Q- n I
Phone#: ? 8� y /-(ipp Z m
Certificate of Competency #: 11 I6 S 00 1 Q
Address: City: State: Zip:
Value of Work for this Permit: $ k0o. Square/Linear Footage of Work: Z6Z 441,
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition
Description of Work:c4p TSS
Specify color of color`thru tile:
Submittal Fee $ Permit Fee $ ((__Q , Com" CCF $ -' .M �� "t z_ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
Double Fee $
Bond $
TOTAL FEE NOW DUE $
A r r--^0aP T,
Bonding Company's Name (if applicable)
Bonding Company's Address
City
I State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
Zip
h_w 1
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 fe6Will- be charged.
Signatu ��
OWNER or AGENT
The,foregoing instrument was acknowledged before me this
d l— 20 by
cc
�'�bdho is- pe�rQsonally known t
me or who has produced S `N.� lT�- WQ
identification and who did take an oath.
'!l
CONTRACTOR ti
The foregoing instrument was acknowledged before me this
S day of 20 y
b
l"EbN�Ls sAIl1,kn�ow'n to
me or who has produced I����L-�lvAe
identification and who did take an oath.
NOTARY
LIC:
NOTARY P
IC:
Sign:
Sign:
Print: j N17 ll, "J1
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Nbi
Seal:
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Notary Public State of FloridSeal..
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Sindia Alvarez
ft Notary Public State of Florida x
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My Commission FF 156750
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Expires 09/0312018
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APPROVED BY
(Revised02/24/2014)
/6 Plans Examiner
Structural Review
Zoning
Clerk