RF-19-2886 (2)EXTERED
Miami Shores Village
DEC 05 2a9
�� Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 RYA '
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2011 �
BUILDING CANCELLEK; Master Permit No. W12-1 I —'
?-
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS [:]CHANGE OF [—]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: \ C� CAQ \,� t \ (O S ST
City: Miami Shores County: Miami Dade Zip: 3313 9,
Folio/Parcel#: o%.12> —0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): C)SCC,v- LG,p-_\-n Phone#: 3os -,?3 b
Address: \ Q %3 N C I nS ST
City: H \ ao i �S YZO if -P S State: F U zip: 3 � 13(r3
City
Tenant/Lessee Name: �� Phone#:
Email
CQ(VTRACTOR: Company Name: � G \`�'�e Phone#: 305 - 301A - 44
Address:
City: V-- \ o" c, \ - State: 1l-. zip: 3�0 3q
Qualifier Name: Yod U� l�L C4 Phone#:
State Certification or Registration #: QQ Cy55 O05-5 Certificate of Competency #:
/91MM
DESIGNER: Architect/Engineer: Phone#:
C,t,
Andress: City: State: Zip:
Value of Work for this Permit: $ 1 o , to() . on Square/Linear Foot ge of Work: 1, 320
Type of Work: ❑ Addition ❑ Alteration El New Repair/Replace ❑ Demolition
Description of Work: \4-, e,—
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
02. ,
Scanning Fee $ Radon Fee $
.ti
Technology Fee $ Training/Education Fee $
Structural Reviews $
F on
CCF
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $ �' Cl�
(AdMed02/24/2014)
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
ux,
136itding Company's Address
11
_ V11
pity 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.....
.u�
fV1INER'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
MOBTAIN 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 the recorded notice of commencement must be posted at the job site
�pi'the first inspection which occurs seven (7) days afte 1 .. g permit is issued. In the absence of such posted notice, the
iy*ection will not be approved and a reinspection fee - Will be c d.
Signatui,� \\ 4t___\ \ Signature / /
ENT
CONTRACTOR
fihe foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of Z) PC Fi AwV3Q/'( , 20 by � day tof ,a JQ (� Q/VVti � , 20 by
�SC&( 2c,, "a rA who is personally known to V � l__)Qyf!1 , wh is personally know o
me or who has produced OV-1 as me or who has produced T` as
f-:identificationF-4-
i e " � �—
t. +' Notary Public State of Florida
��
Jacqueline Barrios
NOTARY PUB
i" —, M PCommission GG 190433
Ex ves 03120/2022
identification ar&6
NOTARY PUBLI�-
Sign
Print: �J�(it �11��,�(� itJfivC��U� Print:
t;sf" .
' eal: Seal:
Notary Public State of Florida
Jacqueline Barrios
My Commission GG 196433
Expires 03/20/2022
4• �c
APPROVED BY Plans Examiner Zoning
i ,y}•
3 Structural Review Clerk
(Revised02/24/2014)