REV-19-91Miami Shores Village , - r ]ED
Building Department JAN 15 09
10050 N.E.2nd Avenue, Miami Shores, Florida 33138'
a (305)756-8972
INSPECTIAN U BER: (305) 762-4949
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BU I LDI Master Permit No. 4 -12 ' 13 " 21 c13
PERMIT APPLICATION Sub Permit No. V-cy I c) I
❑BUILDING ❑ ELECTRIC ❑ ROOFING Ej"REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: f2 -S 7t, I1 £ cT y f A S i v-eGt
City: Miami Shores County: Miami Dade Zip: 33139
Folio/Parcel#: 113 20.s O/ 0 0 2/0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): oN /e'ems Phone#: 3�" �V'
L•
Address: 4-20O AJCF q 4t % S 6-ect
City: Nigon 5h? e.S State: FL Zip: 33138
Tenant/Lessee Name:
Email
Phone#:
4•,. CONTRACTOR: Company Name: o /t Or ��e*14 4s.b; ►G �1jx Phone#: �S ��s� 04 �s
Address: 2Gss Sw 335-4 �}•�VWL
City: Al jctwi State: F(I Zip: 33 f 3 3
Qualifier Name: Ma V i
State Certification or Registration #: C. FL- I W W 3 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Add
City: State: Zip:
Value of Work for this Permit: $ 0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify coIW6` color=thru tile: _
Submi al Fee $-=r Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(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 State
Zip
E�
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. 1 . . ,
"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 permii. 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 is d. In the ab ence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Pwm b; �.
Signature l Signature
OWNER or AGENT 'CONTRACTOR
The ffor ( oing instrument was acknowledged before me this
-1 day/of JAN/ _/� UOL 20 q by
NA124 A- C.dV►`tKS j , who isle nualiy Icnewn to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:KU
DEA
Seal:
My COMMISSION 0 FF9655ft
,p.�'c EXPIRES February 29. 2020
APPROVED BY
Theforegoinginstrument was acknowledged before me this
day of lJ 20 P? by
`b of
t-�F — who is personally known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Print:
L.41)"
ESSICASeal: DICICGRUDERMyCOMMISSION g FF965598
EXPIRES February 29, 202039D-0'b9
Plans Examiner
Structural Review
as
Zoning
Clerk
(Revised02/24/2014)