REV-19-2687G Miami Shores Village RECEIVED
Building Department N V 12 2019
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
I: (305) 795-2204 Fax: (305) 756-8972 BY: �vV`
\/ INSPECTION LINE PHONE NUMBER: (305) 762-4949
tiNL-k ;l- - r, FBC 20(-�
BUILDING Master Permit No. fid -0--1q -165S
PERMIT APPLICATION Sub Permit No. Py-V -f(—IGI- 26;9--�
❑BUILDING ❑ ELECTRIC ❑ R iOFING LREVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUiBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I A
City: Miami Shores
County: Miami Dade Zip: 3
Folio/Parcel#:
Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction
Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
Phone#:�I11�y I
�R — �r 1r- i34`
Address: LF9 tgf.T
City: B 1 lam 1 S holes State: 'El Zip: 33I39
Tenant/Lessee Name: i Phone#:
I
(r'
Email: r
CONTRACTOR: Company Name:
(1 l Phone#:
Address: 1o'50 &W c
City: .'aCT &4
State: E I ZIP: �R, 1L%
Qualifier Name: 2 OdC
Phone#:
State Certification or Registration #:
Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: State: Zip:
Value of Work for thhi ermit: $
Square/Linear Footage of Work:
Type of Work: L`J Addition ❑ Alterati
n ❑ New ❑ Repair/Replace Demolition
pVGDescription
of Work:
Uf
I
LT
Specify color of color thru tile:
Submittal Fee $ Permit Fe
$ CCF $ CO/CC $
Scanning Fee $ Radon Fe
$ DBPR $ Notary $
I
Technology Fee $ Train
ng/Education Fee $ Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ l 00
(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 issue In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged. XI
Signature
Signature
OWNER or AGENT
CONTRACTOR
The foregoing instrument was acknowledged before me this
The fore/oing instrument was acknowledgeVore this
(J T day of 20 Jq_, by
_9 �_ day of JIOUCM�cr 20I�by
(lUe IQ�:Ctfi Idd who is personally known to
Cnjt ey P(AC((1d�, who is personally known to
me or who has produced Fl V as
me or who has produced as
identification and who did take an oath.
identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
Sign:
Sign:
Print: h& SG
jl_
Print: Si1C0tff(11 &IUL{d1
Seal: YOLsA
Seal: YO.WA9"014
S 354385
'� MY COMMISSION M GG 35M
MY"
•: EXPIRE3: poly 14.2023
r a`,: EXPIRES: July 14, 2023
•'!o'i ���' Piblc lhfderwtlters
Pubkems' Bonded Ttxu Notary
APPROVED BY Plans Examiner
Zoning
Structural Review Clerk
(Revised02/24/2014)
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