MC-16-2158Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 79S-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20JO
BUILDING Master Permit No. t-
r-
k I G
PERMIT APPLICATION Sub Permit No. A-1 & 2 -ISP',,
BUILDING ELECTRIC ROOFING REVISION EXTENSION Z*NEWAL
PLUMBING [4MECHANICAL [:]PUBLICWORKS CHANGE OF CANCELLATION SHOP
City: ,t.-//ll17/
Tenant/Lessee Name: _
Email
State: -z
GGm
Phone#:
i
CONTRACTOR: Company Name: ad IL Phone#:
Address: S10 -/,F
City: /t -//Ccs -ii — State: Zip:3%
Qualifier Name: ";Q12,-. e f'211 z Phone#: bzo
State Certification or Registration #: Certificate of Competency #: C'qC
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $1 Square/Linear Footage of Work:, a' -w•' 3 S Ccs• 'C%
Type of Work: DI Addition [K Alteration New Repair/Replace Demolition
Specify color of color thru tile:
Submittal Fee $ GO • C-0 Permit Fee $
Scanning Fee $ 3 a
Technology Fee $_ 3 . ZO
Structural Reviews $
Revised02/24/2014)
Radon Fee $ 2. 10
Training/Education Fee $
It,/ -Z ' (' CCF $ 0CO/CC $
DBPR $ 2 , (U Notary $
Double Fee $
Bond $ 0
TOTAL FEE NOW DUE $ :Z6 '
CONTRACTOR DRAWINGS
JOB ADDRESS: A/1 C(U"VS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 2.200-012 - 021P Is the Building Historically Designated: Yes NO C
Occupancy Type: Load: Cons i Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 9
L
r C" '7 /I Phone#. 2
Address: a 9fawe a5zlryi
City: ,t.-//ll17/
Tenant/Lessee Name: _
Email
State: -z
GGm
Phone#:
i
CONTRACTOR: Company Name: ad IL Phone#:
Address: S10 -/,F
City: /t -//Ccs -ii — State: Zip:3%
Qualifier Name: ";Q12,-. e f'211 z Phone#: bzo
State Certification or Registration #: Certificate of Competency #: C'qC
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $1 Square/Linear Footage of Work:, a' -w•' 3 S Ccs• 'C%
Type of Work: DI Addition [K Alteration New Repair/Replace Demolition
Specify color of color thru tile:
Submittal Fee $ GO • C-0 Permit Fee $
Scanning Fee $ 3 a
Technology Fee $_ 3 . ZO
Structural Reviews $
Revised02/24/2014)
Radon Fee $ 2. 10
Training/Education Fee $
It,/ -Z ' (' CCF $ 0CO/CC $
DBPR $ 2 , (U Notary $
Double Fee $
Bond $ 0
TOTAL FEE NOW DUE $ :Z6 '
Banding Company's Name (if applicable)
f 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.
c
Signature Signature
OWNER AGENT C TRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 !(w by / a day of 17d 20 /l! by
2 - 1 ' _, who i ersa I wn to ' f'/QZ who ' ersona e Wto
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: // Sign:
Print: o' Vwe Ci Print:
Seal: S®NIA OUERRA Seal: :: MY COMMISSION # FF971557
MY COMMISSION # FF971557 a, •r EXPIRES March 15, 2020
EXPIRES March 15, 2020 awyIN n
un„ .tee :.,--- (107) 3p8 -0t53
JAAPPROVEDBYPlansExaminerZoning
IVY
Structural Review Clerk
Revised02/24/2014)