DS-18-332BUILDING
PERMIT APPLICATION
BUILDING ELECTRIC
Miami Shores Village
Building Departmentartment
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
TFBC
201-7
Master Permit No.
Sub Permit No.
ROOFING REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /, / 0 pE- q7
City: Miami Shores
r
County: Miami Dade Zip:
Folio/Parcel#: -7-z 66- ® j7- Jb-3 D Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Feg.Simple Titleholder): AdAA Phone#:
Ad
City: m 4ii State:
i
Tenant/Lessee Name: Phone#:
Email:
p:
CONTRACTOR: Company Name:/ V"%1 Phone#:% 2}
Address: J )02 -YO
City:
Qualifier Name: 3 {
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $
Type of Work: Addition
Description of Work: t
M
Alteration
Specify color of color thru tile:
Submittal Fee $ .
C
Permit Fee $ _
Scanning Fee $ Radon Fee $
up:_- liiJ
Phone4A '%;W'133
of Competency #:
Phone#:
City: State: Zip:
Q
Square/Linear Footage of Work: -! QQ
New Repair/Replace Demolition
249 CCF $_
DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $
Revised02/24/2014)
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ QO2 . ALO
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 a 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 Signature
OWNER or AGENT ONTRACTOR -,
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
2)40 day of /6 y . 20 /,%3J by day of fO- . /l l 20 by
who is personally known to C!//Q /Owho is personally known to
me or who has producedy aGl' y -- `
as rile or who has produced hw1ge-72 Lj 106*W25W1-as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: %LIG7%C! 4C/ V -T- " Sign:
Print: G' % Print: C/ G v
Seal:
MY
AMAGALYLLPUR
COMMISSION # FF213776
Seal: IVlAGALY LLAPUR
MY COMMISSION # FF213776
r EXPIRES March 25.2019 EXPIRES March 25. 2019
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
Revised02/24/2014)