DS18-3140Miami Shores Village
Building Department RECEIVED
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 OCT 112018
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
F BC 20
BUILDING Master Permit No. pS
PERMIT APPLICATION Sub Permit No.
RfBUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL
PLUMBING [:]MECHANICAL PUBLIC WORKS CHANGE OF []CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: AV W67- //0_1111
City: Miami Shores County: Miami Dade Zip: 3.341
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(FeeSimple Titleholder): aj1a o /L
Address: /0/ A/ r Ila 4'
4
City: 1A14/0/ State:
Tenant/Lessee Name:
1
Email:
CONTRACTOR: Company Name: L / / 64l nsee L Phone#:
Address: 7/// N& lel ,- _ caw
336/
City: a,(A/7 /
n/
St KWU _ KU Zip: 531 r /
Qualifier Name: //
IQp
v` 1)1'1'1k4 /A
Mo
Phone#: 7 37 /y
State Certification or Registration #:(Ery%c1 / Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: ` City: Stated: Zip:
JValueofWorkforthisPermit: $ 110 0 Square/Linear Footage of Work: U co
Type of Work: Addition Alteration New Repair/Replace DemolitioA
Description of Work:
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 $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
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 fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
7 // day of, OG'T1S4zU' 20 / , by
rt ;W!Re llt4i ti'k, who isrsonally kn wn to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
2*4A14)
481' e` 's SANDY ROMERO
Notary Public - State of Florida
Commission # FF 915708
APPROVED BY
Revised02/24/2014)
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of "_4t 20 $ by
D(it who is pe onally kno n to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:2j 4 A!(4D—
Print:-
Seal:SANDY ROMERO
11,
Notary Public - State of Florida
Commission # FF 915708N. t:
OF F,8P? My Comm. Expires Sep 7, 2019
Plans Examiner
Structural Review
Zoning
Clerk