REV-19-669Miami Shores Village VED
Building Department
MAf a, 2a'v
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
2FBC20
BUILDING Master Permit No. RC 17-1482
PERMIT APPLI TION subPer 0. N
EL -1-18-104
BUILDING ELECTRIC ROOFING EN] REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS 7 CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 10007 NE 4th Avenue
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: yes NO
Occupancy Type: Load:___ Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): John & Cristina Butler Phone#:305.970.9419
Address: 10007 NE 4th Avenue
City. Miami Shores state: FL Zip: 33138
Tenant/Lessee Name: N/A Phone#: N/A
Email: cibutlerl02@gmaii.com
CONTRACTOR: Company Name: Kelly Benson Electric Inc Phone#: 954-444-4499
Address:
POI Box 223425
city: Hollywood state: Florida Zip: 33022
Qualifier Name: Kelly Benson Phone#: 954-444-4499
State Certification or Registration #: EC0001385 _ Certificate of Competency #:
DESIGNER: Architect/Engineer: Dan Owens Phone#: 305.610.9490
Address: 2700 N. Miami Avenue # 408 City: Miami state: FL Zip: 33127
Value of Work for this Permft: $100.00 Square/Unear Footage of Work:
Type of Work: Addition Q Alteration New Repair/Replace Demolition
Description of Work:. Minor Adjustments due to field conditions
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ - CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $
Revise602/24/2014(
Bond $
TOTAL FEE NOW DUE $ . ._
Bonding Company's Name (if applicable) N/A
Bonding Company's Address
City State _
Mortgage Lender's Name (if applicable) N/A
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 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 prop is subject to ottoc ent. Also, a certified copy of the recorded notice of commence t must be posted at the job site
for the fi tin ection which oc u seven (7) days after the building permit is issued. In abs ce of such posted notice, the
inspectiowill n t b"dreinspect,llbecharged.
Signal aSignature
OWNER or AGENT CONTRACTOR
The f re oing instrument was acknowl dged before me this
day of i 20 — ` . by
h isonally known to
me or who has produced 1 I Ck I` (?Is
identification and who did take an oath.
The foregoing instrument was acknowledged before me this
day of _t a_fC i1 _, 20 1C) , by
e l T_M(-\SU n who is personally known to
me or who has produced _F–L DL ___ as
identification and who did take an oath.
NOTARY PUBLIC: ..
Sig Sign:
Print: i •a iprr nunoni v.gp(ZgjF Print-
Seal; Ie* *_ i pAY COMMISSION # GG 044602
ber 2, 2020
Seal:
DANIEIAMADOTTA
t.}} ,. Ndaty Public - State of Florida
EXPIRES: Nov4Public Commission M GG 283463
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Borated?hruNotaryUrder.riters ; ark,; My Comm. Expires Jon f1,2023
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Bonded through National Notary Assn.
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
Revised02/24/2014(