RF-15-2783 (2)Miami Shores Village
FD
Building Department OCT 20,5
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 BY —
INSPECTION LINE PHONE NUMBER: (30S) 762-4949 -+-7 i
FBC2-01`i'
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
BUILDING ELECTRIC "_\9 ROOFING REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: Z C-rr NVQ Lz'e
City: Miami Shores County: Miami Dade Zip: 3 3
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Phone#: i'C(o • _3 19I - bS6Z
Address: 'Z, 1 fl
City: "mat-*\ 4z
o c State: Zip: 3 3
Tenant/Lessee Name: Phone#: 2
Email:
CONTRACTOR: Company Name:
Address: ` \\o Sy
City: i:
Qualifier Name: o
State Certification or Registration #: `I SS Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone
Add
Value of Work for this Permit: $
Type of Work: Addition Alteration
Description of Work: —
City: State: Zip:
i Square/Linear Footage of Work: r3-,70-40
New Repair/Replace Demolition
Specify color of color thru tile: C_ cA
Submittal Fee $ Go - cx3 Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Feed$ i
Structural Reviews $ Bond $ l
TOTAL FEE NOW DUE $ ` 9. -:30
Revised02/24/2014)
anding 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 fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
S6 day of U t 'C 20 I S by
who is personally, known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
r
Sign:
Print: O IvOZQ
The foregoing instrument was acknowledged before me this
3\ day of U1 a 20 15 by
C C® CsQ N nvho is personally known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign
Print:
as
Seal: EDUARDO A ESPINOZj, Seal o P"Y.P e DENIARODRIGUEZ
e ' *
MY COMMISSION # FF 156456
MY COMMISSION # EE87257G EXPIRES: November 30, 2016
EXPIRES February 07, 2011 4
N07) 3i60 Nl r orcti°°
BondedThruP,udgetNotaryServices
APPROVED BY
rI
1r Plans Examiner Zoning
Structural Review Clerk
Revised02/24/2014)