CC-19-1912BUILDING
PERMIT APPLICATION
Miami 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
CANCELLED,
A is 199
BY:
FBC 201
Master Permit No. 0-01-0G ` 0 `I q I 2—
Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [-]RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: l o ?a Alt z1_ AL&l /Lg
City: Miami Shores County: Miami Dade Zip: 5.313R
Folio/Parcel#: /,� — 2 r 3 b " 013 " 07V Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
.ay-T{fiEL ---Phone#:OWNER: Name (Fee Simple Titleholder): STaL�Il
Address: 10390 AZL2 4V&
City: —,f Am / SIF/y 5 State: 05L. Zip:
Tenant/Lessee Name: Phone#:
Email: -;t n S d
CONTRACTOR: Company Name: f�'/UAfL M4;5115'4 Phone#:.3(�,t - lii --77% 7
Address: .359-0 'All' 1 Y
M�7.
City: /NI 4L State: ��L Zip: 331 7
Qualifier Name: ►%�y� f ri�gf //y� Phone#: 305 Or- 7-7 �
State Certification or Registration #:
Certificate of Competency #: /2 / 7
DESIGNER: Architect/Engineer: Q[�A Phone#:
Address
City:
Value of Work for this Permit: $ 36 6 L7.1OD Square/Linear Footage of Work:
Type of Work: 0 Addition ❑ Alteration ❑ New ❑ Repair/Replace
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
CCF $
DBPR $
Zip:
❑ Demolition
CO/CC $ _
Notary $,
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
j,Bondimg Company's Name (if applicable)
Bonding Company's Address .0VIA _
T"
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
WE
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 inspecti5p v
dhich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will noto-approvelq and a reinspectionIge will be charged.
Signature
O\
The foregoing instru rr
"Z4 day of
4e2 - ?-.-t VV-- &-
B rs
me or who has produced
or AGENT
acknowledged before me this
20, by
o is personally known to
as
identification and who did take an oath.
NOTARY PUBLIC:
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
2�0 day of J�y 120 by
Gl on hri n G who is to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
as
Prin . ta� a Cb � � Print: ( L
� � i man m
Se seal: COMMISSION # GG264921
EXPIRES: October 3, 2022
LAUREL MARCCHARLES
EXPIRES: July 29, 2M
APPROVED Y'`��'«tom° 8°"d°d71'"'NotaryPublkumisnrtlters11 Plans Examiner (� / y3 1 Zoning
Structural Review Clerk
(Revised02/24/2014)