REV-19-92Miami 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 'V
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PERMIT APPL
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❑ BUILDING ❑ ELECTRIC ❑ ROOFING It REVISION
RE�Fi\1ED
JAN 151019
FBC 200
ster Permit No. 44' i 2. —P— 2?13
Sub Permit No.z-V [
t _ `--li2
❑ EXTENSION ❑ RENEWAL
[]PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION SHOP
�, 0 CONTRACTOR DRAWINGS
JOB ADDRESS: (20 GE -7!` 54ree T
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): A*A A' C� 4reees Phone#: 30_15106K-76k 3
Address: 1200 /l.66 % 9 g4r4Z7-
City: 94iA'µL1t U kc4a aJ State: �/ zip: 3 3 1393
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: %r e►% l ` � N� c�� C���64 Phone#: 4'0 t—%4'ft')
Address: S00r Col`.+1
City: A45
Qualifier Name:
` _ zip: '"1X0
State Certification or Registration #: (20-(0 Ova t3 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:
City: State
Value of Work for this Permit: $ D Square/Linear Footage of Work:
Zip:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
_ Description of Work: _[si iblY -7l AAAS'UL kr?vJ-j' Jgiyg
Specify colorii
Submittal Fee $
Scanning Fee $ _
Technology Fee $_
Structural Reviews
(Revised02/24/2014)
2 co for ru >tile:
Permit Fee $ CCF$" CO/CC $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
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
Zip
State r 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 Signature �OWNES or AGENT CONTRACTOR
The foregoing instrument was acknowledged beforemethis The for going instrument as ac mowledged before me this
dayof 20 1 , by day of 0� 20 by
/t
.who is peraW4 k__r .n to who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY LIC:
Sign: Sign: � c.0 �-! - sw.c
Print: lC 4s��2 Print:
Seal: :° J Z SICA D 49CGftUDE ; ''e, PERLAM.OJIRCIA
Seal:
.4 n FF9E « «I MY COMMISMON / 00142111
p�,L�,flc > r: S �ny�Iy� ,.t EXPIRES; January 71 2022
�=� : H r1Uw.ryjytygp. t r •1' kndodThlu py pV�
######################################## #################################################################
APPROVED BY 1 ` �� %lans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)