REV-19-366RECEIVED
Miami Shores Village FE 15 2019
Building Department sue:
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ' I
Tel: (305) 795-2204 Fax: (305) 756-8972 ���
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 201�
BUILDING Master Permit No �- 0),
PERMIT APPLICATION Sub Permit No.
❑ BUILDING ® ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /S O NZ_
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: "-0/3 - - 5 71� Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): S/fc ff4 ti�� C_l3�� �'7 k/TC� Phone#: �TC �Z/(J' ('''%
Address:
City: i�/i///// �r�i�Z�2F_� State: f- L Zip: .33/3il
Tenant/Lessee Name:
Email
Phone#:
CONTRACTOR: Company Name: 1 U/y �f7W r "� &/t-%772 C !C Phone#: t
�—
Address: �� � � . l � I
City: (:h ,� C �r f'f State: (�_ Zip: CG I CU
Qualifier Name: %tip/}-t\/ D CJ C lJA Phone#:
State Certification or Registration #:,/ ��'��} "SC( �{ 'Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $ // I GG
Phone#:
City:
Square/Linear Footage of Work:
State:
Zip:
Type of Work: ❑ Addition 0 Alteration //❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: /2-cV/ .S / G'0L�
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
(Revised02/24/2014)
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF S
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ �p
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 ins ection which occurs even (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will n e proved and o r 'nspection fee will be charged.
Signature Signature —
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of � 4� , 20 1 by
$%'r�4 �►� Ce4 /i/4i�who is perso nown
me or who has produced
The foregoing instrument was acknowledged before me this
day of f L� 20 1 f , by
�1VI t1 4t )iU au,L, ,,,, /t?o is personally known to
as me or who has produced
identification and.,eVd)d taketfqpq&ICE$ identification and who did take an oath.
NOT PUBLICS . MYCOMM1961oN#GG078130 NOTARY PUBLIC:
EXPIRES: March t 2021
as
r"OF FLOP Bonded Rri B46M NotaryServices I I 111!/i// .
'DI7Qz�4,��o���i
Sign: Sign:
Print: Print: `' A!
sr -
Seal: Seal:
G //////11119I1Mf110\\\
APPROVED BY ( 1 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)