RC-19-2188 (2)Miami 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 FBC 20
Master Permit No.
BUILDING Sub Permit No.
PERMIT APPLICATION ROOFING ❑ REVISION EXTENSION ❑RENEWAL
❑'BUILDING ❑ ELECTRIC ❑ SHOP
MECHANICAL ❑PUBLIC WORKS [] CHANGE OF [] CANCELLATION ❑DRAWINGS
❑PLUMBING ❑ CONTRACTOR
�� Y ov - 3
!OB ADDRESS: Zi
Count : Miami Dade
Mi mi S ores NO
Cit Is the Building Historically Designated: Yes
Folio/Parcel#: — BFE: FFE:
Load: Construction Type: �—
Flood Zone:
Occupancy Type: y S R' I Cf U
w A C g Phone#: 3 -
OWNER: Name (Fee Simple Titleholder): /� of �i
3
Address: 5� 'TL Zip: 3 3 Q
City:
Tenant/Lessee Name:
Email:
I- ' ! State:
hone#:
rllVllcn. % 7 2 �% I • 1
CONTRACTOR: Company Name:
Lc Z c`i7 �-i✓Y""�—
Address: 5 s
olr
State: Zlp.
City:
Qualifier Name: v i'^-`
r'r' 10' S Phone#: _
State Certification or Registration #: G13 G 1 3- (. l 5 5 Certificate of Competency #:
_
Phone#: _
DESIGNER: Architect/Engineer:
City: State
Address:
Value of Work for this Permit: $ Square/Linear Footage of Work- _
f-1 rl °'elro til;r;°r_ Y;�:New ❑ Repair/Replace
Zip:
0
8
I;,g1dirg Company's Name (if applicable)
Bording Company's Address
Zip
LAY
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
Zi
State
City
insta
lation has
Application is hereby made to antof
�aa permit and thatwork
wo kinstallations
performedctoemeet the standards of all rlaws (regulating
commenced prior to the issuance
construction in this jurisdiction.understandTANK AIRCONDITIONERSETC
pe permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS
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 Signature
OWNER or AGENT C TRACTOR
The foregoing instrument was a
1 2— day of
me or who h s produce
identification and who iJld t e
NOTARY PUBLIC:;
cnowledged1before a this The foregoing instrument was acknowledged before me this
0 Z_� y`Z day of 20by
perso I cnou n to i '� 61�i who �ersonallyto
io has produced
Ition and who did take an oath.
ter.:
PUBLIC:
as
Print: J - l nt Irl
Seal:
r ' �� JQNIFQftL.�ONOA
MY COMMId/VON N 00 OW52
• {xPIRl11 July H1, 021
:� � � Pub�e IlneWwf<W+
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APPROfIED B Zoning
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