WS-17-1077BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
Miami Shores Village �'
Building Department NR 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 2014
"0' NCELLED Master Permit No. s t —011
Sub Permit No.
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /05'3 k -E ,/ LI -P' 54-
Folio/Parcel#: - 32-05 -'' 0) 2,-- " d Is the Building Historically Designated: Yes NO -
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
DAVID
OWNER: Name (Fee Simple Titleholder): G D v ELIC
— g953
Phone#:
Address: / 0-5"3 NG q y 41'� S k,
City: j'lr .cam i -e-_ 1-yaV State:
r12�
Zip: 333
Tenant/Lessee Name: /� '101—
Phone#: --? oy - 153
1
Email:
CONTRACTOR: Company Name: �� b �� ay )ZD�e Y -,L
rf Z*-njy1 a Phone#:
Address: Z-2iD 5 A cck) (i x'22 f_- a-% VI-tt
City: Iry 7cuyln� State: L
zip: 3 318 )
Qualifier Name: ��6—V+ 61-y' 1^,
Phone#:
State Certification or Registration #: 1 5 2 O G !4 0
Certificate of Competency #:
DESIGNER: Architect/Engineer: Y nano I fe.5--✓r'r
n��+ Phone#:
Address: (��� �_
I1
City: ► 041k- " State: •rL Zip:
Value of Work for this Permit: $ z4 -t Square/Linear
Footage of Work: N/e�
Type of Work: ❑ Addition ❑ Alteration ❑ New ®Repair/Replace ❑ Demolition
Description of Work:
22 C)�ir�C.t c
Specify color of color thru tile:
Submittal Fee $0 t Permit Fee $ D ' CZ CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $ Z O C^
(Revised02/24/2014)
DBPR $
Notary $,
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 'G Q I - ®o
C
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
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. k.. , 11 , 1 , . ,
"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 -on 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 Signatt
„l�
OWNER or AGENTU/instrument
CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoin was acknowledged before me this
_ clay of r 20 by day of r 1 20 I by
CSV d. -W , who is personally known to Y • v i' -f lin who is personally known to
r �YiV'e� 11C�hsp as
me o� who has produced ��- � C 110 l �a 1 1 d me or who has produced
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC:
o!
NOTARY
Print: 1 Print: gnQG�
Y `i T'
Seal: '�
Elizabeth Yelin Seal: LL -s YA PRIETO
ry My Commission FF 063558
Expires 1011612017 MY COMMISSION g FF 214031EXPIRES: March 25, 2019Bonded Thru Notary Public Underwriters
APPROVED BY I� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)