WS-15-2252 (3)L' f`1
BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
SEP 0 3, 2015
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING ELECTRIC ROOFING
FBC
Master Permit No.
Sub Permit No.
REVISION EXTENSION RENEWAL
PLUMBING [:]MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATIONHOP
CONTRACTOR fsDRAWINGS
JOB ADDRESS:y /V (7//(MW 4OUIZ& t
City: Miami Shores County: Miami Dade Zia•
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Zi, Phone#: 3 Z
Address: rVj e n 6V41
City: , State: Zip:
Tenant/Lessee Name: Phone#:
CONTRACTOR: Company Name: DE., &JwytuiA/4- 4 4A)kk . Phone#: 3/2, 6 J' /
Address: &4- jb— XI I-ev" j. f a w
City: _ Stat '3_3)-__-07
Ziip:
Qualifier Name: Phone#: I CJI Z o 1-/
State Certification or egistration #: LG Z 2• Certificate of Competency #:
t
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ (/Square/Linear Footage of Work:
Type of Work: Addition Alteration New Repair/Replace D m lition
Description of Work: 4(10W SQja/LS ''I 44,110 .
1//L / J2 7/f_N /L / / /1l T1 Ln •.w i
Specify color of color thru tile:
Submittal Fee $ 56
cv
Permit Fee $ Z Q w CCF $ CO/CC $
Scanning Fee $
Technology Fee $_
Structural Reviews $
Revised02/24/2014)
Radon Fee $ DBPR $ Notary $
Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE $ V
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection ee will be charged.
Signature Signature
OWNER or AGENT I CONTRACTOR
The foregoing instrum nt was acknowledged before me this The foregoing instrument wa acknowledged before me this
0'.9 day of 11796a- 20 , by 02 day of .GM:I/ 20 b
who is personally known to 4Z412 who is perto_ny 4n_,.__rnuiLto
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign:/ P Sign: P,
Print: Print: A
Seal: SONIA GUERRA seal:
SONIARAGOER
MY COMMISSION # EE177348 MY COMMIS31pN EE177348EWWSMarch .2018 jet-' EXPIRES March p8.20181b1**** * *** ******************** - - - -$ *
oa*m **** **********
APPROVED BY Plans Examiner Zoning
Structural Review
Revised02/24/2014)
Clerk