WS-16-2201OWNER: Name (Fee Simple Titleholder
Address:
Q
4/ - e,
City:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address: /3/ w
City: 6eQ.G
Qualifier Name:
State Certification or Registration #:
hone#: 3l o5-.02
State: IzL Zip: 33/3,p
Phone#:
State:
rl _ 10
Certificate of Competency #:
S 56P3 (0
Zip: 3 3
p 3/2 Co Sl /
DESIGNER: Architect/Engineer: Phone#:
Address: (` City: State: Zip:
Value of Work for this Permit: $ -2/- 1 ` C'y Square/Linear Footage of Work:
Type of Work: f Addition
ryAlteration
cam
New ElRepair/Replace El Demolition
Description of Work: 1 v V -1 > cc) t
Zai
101-
7 , _1• Iznzle . 'O `.5
Specify color of color thru tile:
Submittal Fee W Permit Fee $ zz) u
Scanning Fee $ Q r CjZ) Radon Fee $ U
Technology Fee $ 9 Training/Education Fee $
Structural Reviews $
Revised02/24/2014)
1- 2 Z D_
CCF $ !9C-) CO/CC $ Q
DBPR $ ' J Notary $ 10
460 Double Fee $ '0
Bond $ 0
TOTAL FEE NOW DUE $ 2 3.90
Miami Shores Village AWG 0 4A2016
Building Department BYbaha
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 /0
BUILDING Master Permit No. /2e/l0-196
PERMIT APPLICATION Sub Permit No. Wy ; (G— LG()I
qUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION gSHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: v O 29,117yrVS
0
City: Miami Shores County: Miami Dade Zip• - /33
Folio/Parcel#: lZr! w - O/,3 o2/0 Is the Building Historically Designated: Yes NO >C
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder
Address:
Q
4/ - e,
City:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address: /3/ w
City: 6eQ.G
Qualifier Name:
State Certification or Registration #:
hone#: 3l o5-.02
State: IzL Zip: 33/3,p
Phone#:
State:
rl _ 10
Certificate of Competency #:
S 56P3 (0
Zip: 3 3
p 3/2 Co Sl /
DESIGNER: Architect/Engineer: Phone#:
Address: (` City: State: Zip:
Value of Work for this Permit: $ -2/- 1 ` C'y Square/Linear Footage of Work:
Type of Work: f Addition
ryAlteration
cam
New ElRepair/Replace El Demolition
Description of Work: 1 v V -1 > cc) t
Zai
101-
7 , _1• Iznzle . 'O `.5
Specify color of color thru tile:
Submittal Fee W Permit Fee $ zz) u
Scanning Fee $ Q r CjZ) Radon Fee $ U
Technology Fee $ 9 Training/Education Fee $
Structural Reviews $
Revised02/24/2014)
1- 2 Z D_
CCF $ !9C-) CO/CC $ Q
DBPR $ ' J Notary $ 10
460 Double Fee $ '0
Bond $ 0
TOTAL FEE NOW DUE $ 2 3.90
I
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 then Fpsence of such posted notice, theinspectionwillnotbeapprovedandareinspectionfeewillbecharged. ' 1
Signature S
0 NER or AGENT
The foregoing instrumentwasacknow edged before me this
day of rIv S 20 1(a , by
who is uersona-1111ALknown to
me or who has produced / as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: SONIA GUERRA
MY COMMISSION # FF971557
EXPI ES Ma 15, 2020
I * * * * *
APPROVED BY cA9%'1111- 1 1 -
Revised02/24/2014)
The foregoing instrument was'acknow edged before me this
day of Al ,s 20 Z( by
who is personally known to
me or who has produced
12zigr l as
identification and who did take a oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
SONIIA GUERRA
i •c MY COMMISSION # FF971557
I*S*M** ****020
306-0163 com
Plans Examiner
Structural Review
Zoning
Clerk