WS-19-1300 (2)Miami 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
TND
FBC((�� 2022
Master Permit No. UJ- Ob �N
Sub Permit No.
❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:3� '� 1 S� rC��
City: Miami Shores / County: Miami Dade zip: 33 118
Folio/Parcel#: ( 2D6 — 013 -'F2 ! ( Is the Building Historically Designated: Yes NO
Occupancy Type:_ Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):���CG ��\GC Phone#:
Address: 33� N 1G1
City: \� to u k S�A C--,(CS State: 1� L Zip:
Tenant/Lessee` Name: 11 Phone#:
Email: �c UQ,rc0 .°CCr..�� L1C CG• COVE-,,
CONTRACTOR: Company Name: 1 1 t7y %irks-5 1`e I Phone#: 2( 30_(; - 3q C1- ! `
Address: 208C5 "E 3ZJ Ave
City: Ayer��c ca State: r k.-^ 3e. Zip: '3319
Qualifier Name: ' lo.niP� �io`�rn Phone#:
State Certification or Registration #: 03C- t ZS 9 96 Certificate of Competency #:
DESIGNER: Architect/Engineer: Ee-"r C I�ct--Y(-�iStc�nc Phone#: aL. ZZ3 . S qoq
Address: 1O�L S W I q ro�r1 City: M(c•..nn i State: F_ zip: 33M(z
Value of Work for this Permit: $ Zy G • oo Square/Linear Footage of work: y V) 5q .
Type of Work: ❑ Addition
Description of
❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
�00 CCF $ 1 S CO/CC $
Training/Education Fee $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ �• 4
(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
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 reinspectjgn fee will be charged.
Signature
R or ENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
3G day of Air i I 20 \ i by day of , ' `� 20 , by
u(1 CC r- S who is personally known to GI ✓L I �� ✓1G < <-✓) who is personally known to
me or who has produced
identification and who did take an o
NOTARY PUBLIC:
Sign:
Print: W &LANDER
MY 00WOISSION #GG130146
Seal: SPIRES: AUG 01, 2021
C° Bonded through I st State Inser011
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
as
******************************* ***************************************************************************
APPROVED BY All �'� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Inspection requirements for:
Windows, Doors, Skylights or Fixed Glass (cladding) Permits
Upon issuance of permits for the scope of work involving the removal, changing and/or
replacement of any type of windows, doors, sidelites, skylights or fixed glass (cladding)
the permit holder or qualifier bearing his signature on the permit application shall abide
by the requirements of this department and comply with the following statement:
Upon obtaining window and/or door permits for the installation of same, it is the
responsibility of the permit holder to request window/door framing in -progress
inspection, prior to concealment of any horizontal or vertical clip mullion, bucks, shims,
etc. Inspector will also verify anchor type, edge distance, embedment and spacing. The
purpose for this inspection, is for the verification of conformance with Product
Approval (NOA).
Acknowledgement:
Date Print Name