REV-19-536D
Miami Shores Village MAR 2 2 19
Building Department BY:
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 7S6-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING Master Permit No. RC-- I -lct--1
PERMIT APPLICATION Sub Permit No. P12 - 0- -N - S-3
BUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL
PLUMBING IX PUBLIC WORKS CHANGE OF [:]CANCELLATION F-1SHOP
77CONTRACTOR DRAWINGS
JOB ADDRESS: M -L
Shores Miami
Folio/Parcel#: , 1"' Z ' 3 1 Is the Building Historically Designated: Yes NO _
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): - `\/ r` `-' `^J Phone#:
Address: 6 A C lo -AA
City: e -tS State: C L Zip:
r
3 11
Tenant/Lessee Name: Phone#:
Email
CONTRACTOR: Company Name: ;el iY :54/al?e 60-1-2 Phone#:7W -C 99'
Address: -5" / / ,G L ^/
City: State: /L G,' Zip: 33D 33
Qualifier Name: E'i/I i Phone#: -0
State Certification or Registration #: '.9G j/ S'9 < ' Certificate of Competency #:
DESIGNER: Architect/Engineer:
Add
one#:
City: State: Zip:
Value of Work for this Permit: $ (2J Square/Linear Footage of Work: _
Type of Work: Addition Alteration
1
New Repair/Replace
iption of Work:
PiV{S1oh
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
Revised02/24/2014)
CCF $
DBPR $
Demolition
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ GO
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
Zi
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.
YSignatureySignatureo!57
OWNER or AGENT
The foregoing instrument was
Ia-
cknowledged before me this
Z day of 1'12/Z.h 20 1 0 by
14&": f -)o who is personally known to
me or who has produced as
identification and w I i
Notary Public State of Florida
NOTARY PUBLIC: +: Mycomcommission
Aja Expires 10/1812021
Sign:
Print: (( U /1",
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of /'b!'G 20 ) 9 by
e -r -- -who is personally known to
me or who has produced
identification and who did t
as
d Notary Public State of Florida
NOTARY BLIC: LowMCommitabrt GG 117123
awd Expires 10/18/2021
Sign:
LL I
LLPrint: 4i e) /1
Seal: Seal:
oo
APPROVED BY c/ PI s Examiner Zoning
Structural Review Clerk
Revised02/24/2014)