REV-19-2460BUILDING
PERMIT APPLICATION
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
I
CT17219
BY: `
FBC 20
Master Permit No.OPP-66-11:l- J9Sg
Sub Permit No. Pt— 06— /
❑ BUILDING ❑ ELECTRIC ❑ ROOFING 9 REVISION ❑ EXTENSION [:]RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: CD o f GRAM 0 Coy ! GQ UrSe, DR`
City: Miami Shores County: Miami Dade Zip: 33,1--3�?
Folio/Parcel#: l 1-- 320& - 61 %- 214y Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Load: Construction Type: CZ35 Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): cAkz66 F: L•Gj7?-6S Phone#: 7gG-39a _96;9
Address: �vd% G/ -4A)!' CdiV CQ U/'Se L' /-
City: IVIRA2 State: FL. Zip:
Tenant/Lessee Name: e2W 12 e,"" Q Ccc./l�QIE!' Phone#:
Email• -
CONTRACTOR: Company NameUA%C �✓� NkQPhone#: 7 �35, /y2
Address: 1 1-74 7S. D/ )(1 e 1140Y ?ft
P/
City: / /e C/ /�es]� State: rZ. Zip: 3 �.�5•� q
Qualifier Name: L.(JI.5 9-SPi//o S/� Phone#: 7g6-3 C) � 9.02✓
State Certification or Registration #: C PC-if5 72 8�2�1 Certificate of Competency #:
DESIGNER: Architect/Engineer: Yf F en+-e r1zA)kr �- o Phone#:305-3Q5-'E-:)-556/
Address: 0649y '/jW I d -9 d-�— City: -Dy r/Q[ L State:
r^rl,- Zip:
Value of Work for this Permit: $ / Square/Linear Footage of Work:
Type of Work: ❑ Addition ..// ❑ Alteration ,❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: ��Y� �Gu �iV 7v A4eAJ
hoc474 - 1
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ `-13 • Q
(Revised02/24/2014)
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Bonding Company's Nam-&(tapplicable)
Bonding Company's Address
City _ S
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
WE
Zip
Application is hereby made to obtain a permit to do the work and installations 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 even (7) days after the building permit is ' e . In the absence of such posted notice, the
inspection will not be approved and einspection fee will be charged.
Si nature e ' Si natur
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r3AGENT CONTRACTOR
The foregoing instrus acknowledged before me this The foregoing instrument was acknowledged before me this
�rnrn day of 20 �, by ' �r ,2, day of r 20 _, by
tX��oguern� p sonaUy _ L�IJC� who is person&y- sown to
who is er known to iS tsTl��,
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 PUBLIC:
Sig n: Sign:
Print: Print: I.,
Seal: Seal �,.nY P�,, ELENA A SADLER
�„ ELENA A SADLER . M."
P ;%,
°=°+ay PCNotary Public State of Florida ?2° Notary Public - State of Florida
Commission # FF 924095
Commission # FF 924095 ; My Comm. Expires Dec 13, 2019
******** f'*akc*3k0** ***************** **skE��K+i*BOnd�tltFciu�4�liafieneMi�lote�ytAsi� ****************
,OFF Bonded through National Notary Assn.
APPROVED BY (c �? l Plans Examiner Zoning
Structural Review
(Revised02/24/2014)
Clerk