REV-19-9460
Miami Shores Village
Building Department 0 019,
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 20
BUILDING Master Permit N01�0_` 01, -1 4 - ZA O
PERMIT APPLICATION sub Permit NO-1 C-02 - (q - 3S Z
❑BUILDING [] ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL b
[PLUMBING VrMECHANICAL []PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: _ _ J` q
City Miami Shores
County:
Miami Dade
Zia:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type:
Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
Ctr-e to Q
Cam•
Phone#:
Address: i 1✓ t 5 L
City: J---•-- �---- �o �-- c
state: ► L
Zip: 33 /--
Tenant/Lessee Name:
Phone#:
Email:
CONTRACTOR: Company Name: v*-�'N° Ce'rV ey Phone#: 0
13 S - 2
Address:. _ 1 Lf (_tom C -786 - — b 8 u o �2dVQh
City: �
/4}v�.� State: L Zip: 3 ! 6 ,
Qualifier Name: Al q n,,y Y L I& �r Phone#:
State Certification or Registration M C `Z 5 O 3 '31 ( Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit:
Type of Work: ❑ Addition
Description of Work:
ZQ Cn c aia
City: State Zip
Square/Linear Footage of Work:
❑ Alteration ❑ NewMy
je3 Repair/Replace
rC
A c '"j h w b qs-s
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $
TOTAL FEE NOW DUE 03
(Revised02/24/2014)
_R
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) -
Mortgage Lender's Address
City
State
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 /n 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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
h day of APrl 20 11 by
who is persona�`n to
me or who has produced
Signature _���"`� ///~._ .
CONTRACTOR
The foregoing instrumen was ck ledged before me this
,Q4 �'day of 20 "? by
as me or who has produced
who is personally known to
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PU IC
n:4A � Sign
Sig 'I, t
Print: �A Gl,� L �eZ Print: h�J' l S
Seal: Seat: ,�'r Pue� LUG FERNMNDEZ
fy'w•, ?RACY L LOPFZ a° * W COWA1SSION # GG 00161
AIY COIAMI.4SION i FF 202A79 ��JjEXPIRES: Navenw T, 20N
EXPIRESJur►B 20, 2019 o SWAQ"
BadsdTMuNdWyPW0LWM 1W <o p BOfIdBdThtu8 NOSY
APPROVED BY
Plans Examiner
as
Zoning
(Rev1sed02/24/2014)
Structural Review
Clerk