REV-18-3423Miami 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
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
-
OV 13 2 18
BY
FBC 2011+h
Master Permit No. RC-171-1116 Sub Permit No. �l O )`4-2^
2?
❑ REVISION ❑ EXTENSION ❑ RENEWAL
OPLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1240 NE 91 Terrace
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11-3205-001-0540 Is the Building Historically Designated: Yes NO
-Cccupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
Vg
OWNER: Name (Fee Simple Tittl/
l+eeholde-rr)): � �Car�'� Phone#:
Address: 12gb rJc, lI ._,,rr d4 1.
City: norm, huy)
Tenant/Lessee Name:
Email: I� Roc" ( 2-7
State: i�
gel 01A L
Phone#:
Zip: 331 _15
P �-- `
— �o
CONTRACTOR: Company Name:
/
Phone#:
Address: t 3f25 �
City: ✓Vi e. 1V
State: rc--
Zip:
/
Qualifier Name:
Phone#:
State Certification or Registration #: �������
Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: State:
Zip:
Value of Work for this Permit: $
n,
100 Square/Linear Footage of Work:
Type of Work: ❑ Addition
X Alteration ❑ New
ElRepair/Replace
❑ Demolition
Description of Work:
4/rc Corwl 6a.
11 AfK h ,
tom[ Vi1(�/i,�
Specify color Vlor thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
Training/Education Fee $
CCF $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $ ? /�
TOTAL FEE NOW DUE $ J •y^�
(Revised02/24/2014)
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 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 be approved and a reinspection fee will be charged.
Signature i Signature
p� .Z'� t OWNER or AGENT ONTRACT0R
of The foregoing instrument was acknowledged before me this
,23r� dayof oc4o6Av- 120 i 8 ,by
J)4fVj-P-1 0C4p i L who is personally known to
me or who has produced --dwv>- as
identification and who did take an oath.
NOTARY PUBLIC:
The foregoing i rument was acknowledged before me this
day of N 0\JQq)YXY 20 1 X by
I— Q 0 e Q& who is personal ly known to
me or who has produced as
identification and who did take oath.
NOTARY PUBLIC: AW1
Sign:
Sign:_
//
Print:
Print: _
,•�� n.,
SHERRY M. GORSKI
Seal:
.� �=
Notary Public - State of Florida Seal:
`
Commission # GG 071382
& $.•
My Comm. Expires Apr 7, 2021
Bonded through National Notary Assn.
APPROVED BY Plans Examiner
Structural Review
111`"'"''
°tE
LEIDIANY BARD
MY COMMISSION # FF973551
EXPIRES March 22, 2020
(407) 398-0153
FloridaNwamR—:^& e
Zoning
Clerk
(Revised02/24/2014)