MC-17-2641BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department
100SO N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
RECEIVED
NOV 0 6 1017
W 4-1
5"
�FBC Z0)
�D
(AUCELL Master Permit No. I " C F1
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING [XI MECHANICAL ❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 12 O AV— —I (4 3 i
Folio/Parcel#: ��' 3 2 — 05 — 0 1 1) —o 1 *2 D Is the Building Historically Designated: Yes NO
Occupancy Type: Load:/Construction Type: Flood Zone: BFE: FFE:
� lWyiif 1` 1 L�y l Q q
d. OWNER: Name (Fee Simple Titleholder): /RI(p �•
Address: 1 Z. Co� _ f 4 it5I
City: ) �,1 t>HMre-S State:
Tenant/Lessee Name:_ Phone#: 305. 4333 1.110
Email:
CONTRACTOR: Company Name: I.COZOA.16 MG04A NiCn C GrJrR,w Cn>MSs i nv P• Phone#:(,305�
Address:I 2W O (A)&! T 35 i S
City: 141 Pt-C.A 4 State: t'C Zip: 3 301 z
Qualifier Name: PhoneK. bid 9 7$' 69 W,
State Certification or Registration #: C %'`'IC IZ� O IZ s Certificate of Competency #:
DESIGNER: Architect/Engineer: j4C-7 1-:l,&TGC C JC-, r NCB .-' Ny, Cafe P • Phone#: P'y(- ) 'XL 1 . V-20q
Address: 3,5W S cJ I 1 7- A vD 0 N i wCity: 14 ip ", State: FC. Zip: 3 31(,5
Value of Work for this Permit: $ [� •g SO
Square/linear
�Footage of Work:
El of Work: AddEl�/
Addition ❑ Alteration New Repair/Replace ❑ Demolition
Description of Work: O j 6P Z 14VA C S-1 T-MS
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CF $ CO/CC $
Scanning Fee $ Radon Fee $ 6 • ZE; DBPR $ Notary $
Technology Fee
Training/Education Fee $
Double Fee $
Structural Reviews $ Bond
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: 1 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 OrIcYpproved and a reinspection fee will be charged.
OWNER or
The foregoing instrument was acknowledged before me this
4G day of )(CA)erA�aG 20 1 i by
f''`ZiIQ.�(��IV�G1' ��L� � '��I ✓l ho is personally known o
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
r
Sign: _
Print: eoe_—.)
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
4 day of OcOe ,t kfi-e ' 20 1 i by
�J AJt� 2C—L4 ho is personally knowno
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
as
Seal: Seal:
r � BRITTANY OUIIERO MY COMMISSION #FM5478BRFTTANY OLN8i0
n
EXPIRES: JAN 22,2018 MY COMMISSION #FF0850
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' Bonded thrlluph lit Sfadl hIWIB16�
APPROVED BY �F al �ami er Zoning