REV-19-603Miami 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
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
REC V
MAR 2 20
BY:
FBC 20
Master Permit No. C IS' l g-1
Sub Permit No. V ",2) — q bo
E/REVISION
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
/-*) q 9
JOB ADDRESS: (A t
❑ EXTENSION DRENEWAL
❑ CANCELLATION ❑ SHOP
City: Miami Shores County: Miami Dade Zip:
DRAWINGS
Folio/Parcel#: Is the Building Historically Designated: Yes NO
�C
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Sim1pllel ( e Titleholder): �NS+« * TCuG GQLb Phone#: bc6) (P (3 J l g
Address: a ,III - 3�rtj't {� p
City: k SCAA�I/L '5LQEe�-5 State: RO(Ja- zip: -33 (39
Tenant/Lessee Name: �) I a Phone#:
Email: kx t)oa( (V coif)
CONTRACTOR: Company Name:0Wy)L9'y Phone#:
Address:
City:
Qualifier Name:
Zip:
State Certification or Registration #: Certificate of Competency #: �,
DESIGNER: Architect/Engineer: 9"Ohk TCL- , i , `��Ljn tiet'; -Dno— Phone#: (QJG Jqq I a -ase
Address: `1� nOrb (�a,�w1 N� T F-��.r.�y (9 ( City: H,� ('CU''1\Ctr State: _Cf. Zip: � 3O
Value of Work for this Permit: $�� Square/Linear Footage of Work:
Type of Work: d Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: C
- t\-1 A0 F-t,c,` f P A r
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ (7� Training/Education Fee $
Structural Reviews $ -I 0
CCF $
DBPR $
&u ocrn&"c h an S
as -t tins AA 5
CO/CC $
Notary $ S
Double Fee $
Bond $
^� vm
TOTAL FEE NOW DUE $ ( .
(Revised02/24/2014)
Bonding Company's Name (if applicable)
0A
Bonding Company's Address _
City State nn \\ Zip
Mortgage Lender's Name (if applicable) 1V
Mortgage Lender's Address
City
State
Zi
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 Signature
OWNER or AGENT U CONTRACTOR
The foregoing ` instrum gn/t�was acknowledged before me this
0� day of �� lill`CY1 120 I 1Gby
tL�M who is ersonally known to
me or who has produced as
identificatiorfa-Phiwhodid take —an oath.
ARY PU
Sign:
Print: �►
Seal:
*************
C
YANADY PRIETO
MY COMMISSION Y FF 214031
EXPIRES: March 25, 2019
�.dM Thy, Nntary Public Underwriters
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
*******************************************************
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)