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REV-19-166BUILDING PERMIT APPLICATION ❑BUILDING ❑PLUMBING ❑ ELECTR C ! ECHANICAL Miami Shores Village RECEIVED Building Department JAN23 2j,9 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 201-- Master Permit No. 2 Ey 1a - Sub Permit No._�_ �1 lot E:_) ROOFING ❑ REVISION ❑ EXTENSION RENEWAL E:_I PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: l �w _ L© a City: Miami Shores County: Miami Dade Zip: 3 3�1� Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: __ Construction Type: Flood Zone: BFE: FFE: La - - 3U' 1 2'tt313 OWNER: Name (Fee Simple Titleholder):G1k12tsni NO Phone#: Address:— -1 4J LO D City Rt State: _ ---- --..Zip: Tenant/Lessee Name: Email hone#: CONTRACTOR: Company Name: 4 /k',j v'5 `-)_4Phone#: 50 f 4"5 0 6 � Address: IIZ t::� 1y S W )�a 0- _:�-3' b 5 City: �`State: Zip: Qualifier Name: J a s'� Phone#: ':��DT y Tp b Z'.3 State Certification or Registration #: —��"� G 12 ?� Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Vy Value of Work for this Permit: $ Square/Linear Footage of Work: _ Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ COXC Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Structural Reviews $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ e�7,) 3 (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 WE 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 deliver?!r to the person whose property is subject to attach;•ntnt. Also, a certified cupy of the recorded notice of commencement must be pusreu at the job site for the first inspection which occurs seven (7) days ofter 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. Signs Signature O or AGENT CONTRA TOR The foregoing instrument was acknowledged before me this day of ,�JzC2•rc��er 20 (V by C�r5lfan c�Qhr who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print. Seal: �•�.��Y�,BETSY0*PEREZ Notary Public - State of Florida _• . •` Commission #t FF 182380 My Comm. Expires Apr 3, 2019 APPROVED BY as The foregoing instrument was acknowledged before me this %U day of Q,—La /nn-V 20 10 , by Jost A WIS.- xt who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign:_ Print: Seal: SUSANAECHAGARRUA ifV` n37118 My Com . Expires Jul 7, 2019 Bonded through National Notary Assn. ******************************************************************* Pla Examiner Zoning Structural Review Clerk (Revised02/24/2014)