BPP-19-80'CZIVE]D
Miami Shores Village
Building Department _
BY:
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 —ff
INSPECTION LINE PHONE NUMBER: (305) 762-4949 L
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC ❑ ROOFING
[-]PLUMBING ❑MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: h—D AZ —/ L/ A ':_ `PA
iami Shores
FBC 201
Master Permit No.t*__R_Ia �
Sub Permit No. E C [ - ()
❑ REVISION EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Folio/Parcel#: It 34�/ 1�d- � �Q Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Title p der): +� L'Vv�N ?� _Phone#:�
Address: City: fill.&"�M1 �OIl�S State: `R !— _Zip:
Tenant/Lessee Name: Phone#:
Email: /7
CONTRACTOR: Company Name: R/#7-PI�/ nc;Az hone#: L-•->
Address:
City: .S,b12 State: t-ZL_ Zip: 3 /4/_ G
Qualifier Name: Phone#: 305"
State Certification or Registration #: C A. //S/ �5�3 j Certificate of Competency #: _
DESIGNER: Architect/Engineer: /Cc .v,�� /F� f �/ i /` F` Phone#:
Address: Si'% S. UGC /���" City: /%i State: G Zip:
Value of Work#or this Pe7it: $ Square/Linear Footage of Work:
Type of Work: .❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
5pecif�r color of color thru the:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
(Revised02/24/2014)
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF
DBPR $
CO/CC $
Notary
Double Fee $,
Bond $
TOTAL FEE NOW DUE $ _
Ponding 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 op Hcont must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to he 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 inspec ion which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not proved and a reinsp tion fee will be charged.
t r
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
<' C,
day of 20 ( ' by
T�ho is personally known to
me or who has produced as
N�� as
identification and who did take an oath.
NOTARY PUBLIC:
1
F
Sign:
Print:
Seal: SINDb1 ALVAREZ
MY COMfviISSION r'1 GG 238273
EXPIRLJ: S.,Ptember 3, 2022
Bonde Thru Notary Pub6C Underwniei
******************
APPROVED BY
The foregoing instrument was acknowledged before me this
day of ," Lgpf&w6e,� �J_2Q._ Lc, by
J OS-e 001 o��
nes ( , who personally know..,,nxto
me or who has produced as
identification and who did take an **?�e�
JOFINP.COELLO
= o
MY COMMISSION / GG 076110
NOTARY PUBLIC:±1�`
E:IRES: May 14, 2021
OF FBonded Thru Budget Notary SKAM
Sign:—
Print:..—
JOHN P. Como
MY COMMISSION Il GG 076110
Seal:
+
N��
EXPIRES: May 14, 2021
EeF n°
Baded Thn Budget Notary Sei a
i 7/t� Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)