REV-18-291BUILDING
PERMIT APPLICATION
Miami Shores Village RECEIVED
Building Department FEB 052018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 W
Cf
Tel: (305) 795-2204 Fax: (305) 756-8972 ' _
INSPECTION LINE PHONE NUMBER: (305) 762-4949 S
FBC 20H
Master Permit No. G gI (40—
Sub Permit No. 961\1 5 :91
❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING Q'NIECHANICAL ❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 4?7 0O AV ..
f fd2 Pee
`__1 City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:_ 11 i 2 05;-- l Q // C7 Is the Building Historically Designated: Yes NO x
Occupancy Type: 5. iQ Load: Construction Type: 11_14� Flood Zone: L"' BFE: FFE:
./►'1(✓� 16c) Utzl( C /" Phone#: 305- % lJ 7
OWNER: Name (Fee Simple Titleholder): _ � �C�l
Address: acq
City:
Tenant/Lessee Name:
Email:
�9D
State:Zip: 3 % 3
Phone#:
CONTRACTOR: Company Name: 0C_'f6) 201J H_ / •I.,PC f701'f/f/!i4 C- Phone#: 7 o S' / 7A 6 f6[
Address: 6 YD 1,l1 37-
City: �_//�4L I. if- t7" State: r� , Zip: 3 -z
Qualifier Name: /.a-vi2J2 L Phone#:
State Certification or Registration #: �!?�� Z.S li l yr�� Certificate of Competency #: '�
DESIGNER: Architect/Engineer: �'¢� [ o ��%4! t '.�lP-� /I� Phone#: 3 05 Aml6 2-3 .3
Address: sl C o � � 7 9 A;_ L City: � �G i �N1 :'-State: r L Zip: 3 3�
Value of Work for this Permit: $ (.� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:��� vc�v�i �,/j s j ry ✓�[ i/'S C1�� NC /P f r-n ✓C
Specify color of color.to"'tile-'
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $_
DBPR $
i
- CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ -
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: 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 low 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 Itt be approved and a reinspection fee will be charged.
Signature Signature / �'✓
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before a this The for oing instrument was acknowledged before me this
7) day of 20, by day of by
?G�./_ [�f9/( /s •Ci1 / !whois r onally known �fJ tJ/"� �7`/�/fie. wh i rsonall known to
me or who has produced as me or who has produced as
identification and who did take an oat identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print:
Seal: ;� •�= MY COMMISSION # GG 041376 Seal: • •• MY COMMISSION # GG 041316
EXPIRES: December 30, 2020 el EXPIRES: December 30, 2020
Banded Thru Notary Pubic Underwriters Baled ThN Nafery Pubic Underwriters
APPROVED BY V Lns Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)