REV-19-626\` Miami Shores VillageFez-,-.� .
Building Department MAR 2 z _'J19
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:
9Y�
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 1':'
BUILDING Master Permit No. I�,C �('0- Iq (V'
PERMIT APPLICATION Sub Permit No. ,�� -ID 9' 10I-(0Z0
❑BUILDING ELECTRIC ❑ ROOFING 21REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [-]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
N . ( h "S 0'0�'Lrz
Folio/Parcel#: 11 " 3 2 0 S' b [ r f f Is the Building Historically Designated: Yes r NO N
Occupancy Type: �f_jimoad: Construction Type: �' _Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder: 1/� h Phone#:
Address: 10 a A) . LS lam'
City: rA_ � -f State _F L Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: M%kk
City: N- tam.`
Qualifier Name:
v
i
hone#:
%�us'
State Certification or Registration #: E C, %L61 ,A�ss Certificate of Competency #:
DESIGNER: Architect/Engineer: Ca - vV`'41 �2 Phone#:
Address: _ [ l 8 S-I�tl �,� /[_ S f / D � City: l� , rq ILI , State: _..FL Zip: 3.3 f r s
Value of Work for this Permit: $ c� zs O Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alte ation [New ElRepair/Re lace ❑Demolition
_ �1 � p
Description of Work: /y P< <y �-� C L A L C bz*,, � 1 14ee— J1 d, ✓Lr
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $ tt
TOTAL FEE NOW DUE $ L� c
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 permlissu,In theabsence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of 20 by
who is ersonally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
CONTRACTOR
The oregoing instrument was acknowledged before a this
day of 20
by
who is personally known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
as
'
1
Sign:
Sign:
Print:
'
Print:
Seal:
..".•�•
N
�t::411�
.
f;
CLARtSSA A. ROORIGUEZ
MY COMMISSION 0 GG 041376
Seal:
""""•.
;'gyp"` a CLARISSA A. RODRIGU
s ;t~' •` MY COMMISSION # GG 041376
Dace30,20
:8
's, ay EXPIRES: December 30,2020
.
�R�NS:
��'
1,67 tk S&Wed Thru Notary N* Underwriters
APPROVED BY
1i
Plans Examiner
Zoning
Structural Review Clerk
(Revised02/24/2014)