RC-13-568 (2)Miami Shores Village
Building Department MAR 2 9 .02
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit No.
Master Permit No.'�� ^ ��
FBC 20P CANCEurPermit Type: lectrica 0
OWNER: Name (Fee Simple Titleholder): V / L. M /�1- �r' U � Phone#: 50 J -7 S l 1 I
-1 -- - r � ^- - - --
City: I1�V�j }411/1/1
Tenant/Lessee Name:
Email:LI ( l_ M
State: Zip: 2 `�
I>— I
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: 2
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO
Flood Zone:
CONTRACTOR: Company Name: ouwjr- Phone#:
Address:
City:
Qualifier Name:
State Certification or Registration #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Certificate of Competency #:
Phone#:
Value of Work for this Permit: $ I Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration New ❑Repair/Replace
l�J
Submittal Fee $ `� Permit Fee $ /1 G� �� CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $
❑Demolition
41
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
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 suI * to attachnten lso, a certified copy of the recorded notice of commencement must be posted at the job site
for the Errst inspectio�pLoved
ltich occu se en (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be at a re nspect0h fee will be charged.
11
f
The foregoing instrument was acknowledged before me this
day of , 20 )'?,by `11 Li`t C -"I r—
who is personally known to me or who has produced
`��►uu rrurn�i
As identification and��Ao dicl
��
NOTARY PUBLIC: E%��;
� s
Sign
Print:
Aso'**
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 _, by ,
who is personally known to me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires: ///,i�ZtORI1D►P►``�����x� My Commission Expires:
APPROVED BY ;? Plans Examiner
Structural Review
Zoning
Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)