REV-18-36310
BUILDING
PERMIT APPLICATION
Miami Shores Village RECEIVED
Building Department DEC 071018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 4--fTel: (305) 795-2204 Fax: (305) 756-8972 — j
INSPECTION LINE PHONE NUMBER: (305) 762-4949 (Wti
FBC 20 1:1
Master Permit No. /6 -,
t7
25 a 9
Sub Permit No. tc4
BUILDING F—] ELECTRIC [:] ROOFING §j REVISION E] EXTENSION DRENEWAL
PLUMBING F-1 MECHANICAL PUBLIC WORKS 0 CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 12150 NE 101 g'j'R6S-F
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: RCS- Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): N e,l 4- M (tr i h N6C.G u I y)y-j S S Phone#: 30 S 3 12-' (
Address: SAME
City
Tenant/Lessee Name:
Email:
State:
ne#:
CONTRACTOR: Company Name: H o "e W m a rz- Phone#:
Address:
City: State:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#:
p:
Address: City: State: Zip:
Value of Work for this Permit: $ l %.
4 8 0 d Square/Linear Footage of Work: 12 4 S
Type of Work: Addition Alteration New ® Repair/Replace Demolition
Description of Work: NC I NG I L WOOD V JILOO M.i fes ( ft
f.Lt A Ai.rfl 13 5 i3o rz—
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ ' 00 CCF $ d - 2-0 CO/CC $
Scanning Fee $ 3 Radon Fee $ 5 ' C)q 'DBf PR $ 4 5 Notary $
Technology Fee $ (--' 60 Training/Education Fee $ 3`t 0 Double Fee $
Structural Reviews $ Bond $
T5
J j
TOTAL FEE NOW DUE $ P • U( V
Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
State 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 /YI.Gt.u- C— `
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of ^ ^ — 1 20 I , by
MOT i Q '" tCgUiR'V sonally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
n.
0
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of 20, by
who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: ?*d MY COMMISSION#GG 044602 11 Print:
acovem er 2, 2020
oF F; p- Bonded Th ru Notary Public underwriters if Seal: Seal:
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
Revised02/24/2014)
17
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