REV-18-2110Miami Shores Village
Building Department AUG 8 X018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 B
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20\
BUILDING Master Permit No. -b'-c y)
PERMIT APPLICATION Sub Permit No.12U
�aBUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING F-] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: '98o 1 K)1;—� '�L- AViz�
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: QConnsstruction Type: Flood Zone: BFE: / F.FE:
OWNER: Name (Fee Simple Titleholder): t C.�o 1 Phone#: �2c>S
Address: (4 IAN F
City: ( +) l - State: Zip:
Tenant/Lessee Name:
Email
hone#:
CONTRACTOR: Company Name: G a�SS.�Y:i'r' S ��`�-�� Phone#:
Address: -'�4 � Z�� ZQ ANC
City: rmc-u State: �L- Zip: 1
Qualifier Name: J V P*�J►fir Phone
State Certification or Registration #: � (3C C7 J " ►]J 00 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
aoS — 2 -
State:
Value of work for this Permit: $ LZ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of Work:
Zip:
❑ Demolition
Specify color
co r,
Scanning Fee $ �Z ( - U� Radon Fee $ -?:' ' CJ DBPR $ 4 ' � Notary $
Technology Fee $ -::� -SD Training/Education Fee $ Z - Q
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Structural Reviews $
(Revised02/24/2014)
Double Fee � -
Bond $
TOTAL FEE NOW DUE $ • IZ
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
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signatu
OWNER or AGENT
The foregoing instrumenw s acknowledged before me this The foregoing instrument was acknowledged before me this
JS day o v � , 20 �by Z day of , U 20 � by
who is personally known to UOU (')who is personally known to
me or who has produced
identificati6nJ
'and who
NOTARY
Sign:_
Print:
take an oath.
as me or who has produced 1
identification a�who did take a
NOTARY PUBLI
Sign:_
Print:
MY COMMS )WWA x r ,
Seal:'' '•Seal:
^$ �,�,•:,;
EXPIRES: October 15, 2019
—••ePublic Underwrit8rs
9 ��E�FF:°•' BondedThruNotary
h.
EXP!RES: October 15, 2019
Bonded Thru Notary Public Underwriters
as
******************************** ****** *******************************************************************
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
,SH°Rn
Miami Shores Village
Building Department
10050 NE 2nd Ave.
Miami Shores, FL 33138
305-795-2204 / Fax 305-756-8972
NOTICE TO MIAMI SHORES BUILDING DEPARTMENT OF EMPLOYMENT AS SPECIAL
INSPECTOR UNDER THE FLORIDA BUILDING CODE.
I (We) have been retained by to perform special inspector services under the Florida
Building Code 5th Edition (2014) and Miami Dade County Administrative Code at the
project on the below listed structure as of (date). I am a registered
arch itect/professional engineer licensed in the State of Florida.
Process Number:
— Special Inspector for Reinforced Masonry, Section 2122.4 of the FBC 5th Edition (2014)
Miami Dade County Administrative Code, Article II Section 8.22 Special Inspector for
•
—
• •
• • • • •
Trusses > 35 ft. long or 6 ft. high
• •
• •
•
......
.. .
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— Steel Framing and Connections welded or bolted
•; •
•
—Soil Compaction
."'•.
."".
'
Precast Attachments
......
.. .
see 0
— Roofing Applications, Lt. Weight. Insul. Conc.
.. ..
.. .
......
Other
. .
. .
•
......
Note: Only the marked boxes apply. • •
The following individual(s) employed by this firm or me is authorized representative to perforrr
•
• • • • • •
• •
•
inspection*
1. 2.
3. 4.
*Special inspectors utilizing authorized representatives shall insure the authorized representative is qualified by
education or licensure to perform the duties assign by Special Inspector. The qualifications shall include licensure as a
professional engineer or architect: graduation from an engineering education program in civil or structural engineering;
graduation from an architectural education program; successful completion of the NCEES Fundamentals Examination;
or registration as building inspector or general contractor.
I (we) will notify the Miami Shores Building Department of any changes regarding authorized personnel
performing inspection services.
I (we), understand that a Special Inspector inspection log for each building must be displayed in a
convenient location on the site for reference by the Miami Shores Building Department Inspector. All
mandatory inspections, as required by the Florida Building Code, must be performed by the Miami Shores
Building Department .Inspections performed by the Special Inspector hired by the owner are in addition to
the mandatory inspections performed by the department. Further, upon completion of work under each
Building Permit, I will submit to the Building Inspector at the time of the final inspection the completed
inspection log form and a s etiei¢rp,te ment indicating that, to the best of my knowledge, belief and
professional judgment o. Joe project outlined above meet the intent of the Florida Building
�-O
Code and are in sub t{R drd ei%he approval plans.
••�,� SF's. i� Engineer/Architect
;.' :* Name r Q n kyl.$ .01'15
Fla
Signed d Print
Date: AR Address I( -I245 $w ZL l fA2CQ
STATE OF ��, 33115
�i�•' *'��� �-i(Q+,►�1 t