EL-17-2737Miami 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
FBC 20(q
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BUILDING �n p� Master Permit No.M�s"���
PERMIT APPLICATION "AN V ELLED Sub Permit No.
❑BUILDING] ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: 003/38
Folio/ParcWel#: ��--32�5 �Is the Building Historically Designated: Yes NO
OccupMcy Typ . Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �6A AOM04 � •Phone# �+s• 718 v9 4)l
Address: 17.4o gE dty 3 fl
City: ' 41a rtS State: T L Zip:
Tenant/Lessee1Name:
Email: nh oire.
CONTRACTOR: Company Name:
Address: �(J l " -->
/A/C' •
ne#:
ne#:
City: R1,4101 State: / L- Zip: -3 34
Qualifier Name: m /Zoae) w' , ��an Phone#:
State Certification or Registration #: Certificate of Competency #G� 3d0 3 -71�3
y 4
DESIGNER: Architect/Engineer: rPhone#:
i i. , � F • i is `
Address: City: State: Zip:
Value of Work for this Permit: $ / 9 v V Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration moo❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:L
t
.+ r
Specify color„of',color *P tile:
Submittal Fee $ 174O , (7�1 Permit Fee $ At�'-iV/BO CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 11 (, J r
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
�,.A
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City L 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.
Signatur Signature r-
OWNER or AGENT CONTRACTOR
The foregoininstrument was acknowledged before me this The forregging instrument was acknowledged before me
this
day of N``V keM 4PV- 20 1-9li' by day of /G�`%� � 20 / by
Mdl'tVl #40ta+,A Mop�•ertT�who is personally known to le, "n rMW7 who is personally known to
me or who has produced :2)49)�063 rfYIJ(ui-s me or who has produced as
identification and who did take an oath.
NOTARY P
Sign::
Print
1• rvo[dry ruonc - kale or noriva
Commission i GG 148525
? My Comm. Expires Oct 1 E, 2021
e c- Borded through National Notary Assr.
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
r r Mk bolt Perez
Seal: di My Co nmiss GG 0e4089
or w Exp M 04/0l1 wl
APPROVED BY / /jplans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)