FW-18-175Miami Shores Village Mcyj A,/ r_'" I
18
Building Department
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10050 N.E.2nd Avenue, Miami Shores, Florida 33138 $Y' ----_
Tel: (305) 795-2204 Fax: (305) 756-8972 —r1 j
INSPECTION LINE PHONE NUMBER: (305) 762-4949 ``
FBC 20 H
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
UILDING ELECTRIC ROOFING REVISION EXTENSION 2fENEWAL
F-1 PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF [:]CANCELLATION SHOP
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CONTRACTOR DRAWINGS
JOB ADDRESS: / % -s/k'f
City: Miami Shores County: Miami Dade zip: .3r7 SL
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: 40 ' Flood Zone: X_ BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 1/e C 4S Phone#: ?-R-7-23 -3s YY
Address: 19 A'"I
City: +' .f 1S State: Zip: 33/5v
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Namel
Address:
I
City:
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Phone#:
ne#:
Certificate of Competency #:
ne#:
Address: City: State: Zip:
Value of Work for this Permit: Square/Linear Footage of Work: 2SL)
Type of Work: Addition Alteration New Repair/Replace Demolition
Description of Work: 4-1--dil..Gt 4c.C ,64ceE ',!v A.c-A- .
Specify color of color thru the:
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Revised02/24/2014)
Permit Fee $ CCF $_
Radon Fee $ DBPR $
Training/Education Fee $
1 1
CO/CC $
Notary $ (5KZ5
Double Fee $
Bond $
TOTAL FEE NOW DUE $
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T V
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.
D ;, • Signature Signature
0 ER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
r
day of PLS 20 (9 by
v NA-It—j Nrbic—
who is personally known to
me or who has producedas
identification anRwho did take an oath.
NOTARY PUBLI
Print:
Y
Seal: ;o`at NouZizn-?UprCStateofFlorida
jrn FF 156750
i
Art Exptres09103/2018
APPROVED BY
Revised02/24/2014)
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The foregointg.instrument was acknowledged before me this
F i.tFi I _} 1
day of 20 by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
4a I:
as
Plans Examiner
Structural Review
Zoning
Clerk