REV-19-2622:c
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
OV d 1 2919
�1%i�A
FBC 20 -` p d
Master Permit No. L OS-{ I `l 1- ! z-
Sub Permit No. -eV_1H _zlUl
■❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
62 NE 109 ST
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11 -2136-011 -0350 Is the Building Historically Designated: Yes NO
Occupancy Type: Residential Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): DAVID HARRISON
Address: 62 NE 109 ST
City: MIAMI SHORES, State: FL
Tenant/Lessee Name:
Email: david@harrisoncrane.com
CONTRACTOR: Company Name: Goldin Solar LLC
Address: 3447 Percival Ave
City: Miami Stal
Qualifier Name: Daren Goldin
State Certification or Registration #: CVC56965
DESIGNER: Architect/Engineer:
Phone#: 305-984-9481
Zip: 33161
Phone#:
Phone#: 480.208.4688
FI Zip: 33133
Phone#: 480.208.4688
Certificate of Competency #:
hone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work: '
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: Changes in the layout - + rn'A
4
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 $ 10 2.
(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 reinspection fee will be charged.
Ar-
Signatur Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
/ day of N10yE41BEQ 20 !9 by
,�AVIP MRRt6014 who is personally known to
me or who has produced FdL
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:'
Notary public Stets of Florida
Seal: :r�� Karen Solano
My Commission GG 339437
`
- wi Expires 05/28/2023
CONTRACTOR
The foregoing instrument was acknowledged before me this
% day of movo"" b'r- 20 C/ by
`Da>t'1 Coo o is personally known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)