DS-17-1006Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PErUILDINGT APPLICATION
ELECTRIC ROOFING
RECEIVED
APR 117017
S
F BC 201'-) "`
Master Permit No. l ( 1 (Dob
Sub Permit No.
REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL [:]PUBLICWORKS CHANGE OF [:]CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 6 70 A57 17 Sr
City: Miami Shores
V
County: Miami Dade Zip:
Folio/Parcel#: 520L ('T16 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): jow .Agj/aO Phone#:
Address: 6,70 NC D 5C
City: Sta 3.Vy
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:( 99O-A t.C,r Phone#: -3M%S
Address: 107,Y0 /VA/ 0 7a&- S
City: I -IL
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Address: City:
Zip: 33/7t'
Phone#: -a23'q &A U3
of Competency #: osgSood'
Phone#:
State: Zip:
c1
Value of Work for this Permit: $ &yo Square/Linear Footage of Work:
Type of Work: Addition Alteration New Repair/Replace Demolition
Description of Work: jIf 40jtt)n-_ < & zopL, .007L "%}lf '-elt S
Specify color of co/or,thru tile:
Submittal Fee $
R-
Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $
Revised02/24/2014)
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
RM
US
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 1# posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absenceofOr
posted notice, the
inspection will not be approved and a reinspection fee will be charged. '
Signature
OWNER or AGENT CONTRACTOR
The foregoing instruments was acknowledged before me this ;'r, ,The foregoing instrument was acknowledged before me this
n16
day of s/Q!'! 20 / 7 by
d : _
a/_ _ day oof /l%/Lf 20 by
f/ efhlll who is personally known to C!/
r/!
r7 lyi fl who is personally known to
me or who has produced /)/-/)/-46 02 , V 61-,7r1 ~ `
6sr
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: 7% YAG ,C-fr- Sign:
Print: Print- kvv r
I AGALY LAPUR
Seal: ; MY COMMISSION * FF213776 Seal:
Y My COMMISSION p FF213776EXPIRESMarch25, 2019 = .
tr07i 398 0 53o„ e,v com ?,,
EXPIRES March 25, 2019
407 398-0 53 FloridaNWaryServicecom
APPROVED BY
Revised02/24/2014)
Plans Examiner
Structural Review
Zoning
Clerk