REV-16-1634BUILDING
Miami Shores Village
Building Department ►R'o
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ( JUN 2 42016
Tel: (305) 795-2204 Fax: (305) 756-8972 ��E
INSPECTION LINE PHONE NUMBER: (305) 762-4949 BY: 5
FBC 201`I s
Master Permit No. V_ Gi b — P
PERMIT APPLICATION Sub Permit No. n--v (le —1-1 (P�
❑BUILDING ELECTRIC ❑ROOFING ❑REVISION ❑ EXTENSION ( QRENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [—]CANCELLATION ❑ SHOP
CONTRACTOR
JOB ADDRESS: 104 0 W I to 2
DRAWINGS
City: Miami Shores Countv. Miami Dade Zip: 7"
Folio/Parcel#: -b2 2 ' (3y Is the Building Historically Designated: Yes NO A
Occupancy Type: Z. Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
Address: 10
VC
one#: TB b ''3) 6 - %, [ 0
City: KA G . S[ uJou State:1,-,L_ Zip: 3'3(jy
Tenant/Lessee Name:
Email
0
CO kAX, ,
one#:
CONTRACTOR: Company Name: �I OQ v �eC- C _ Phone#: o Zit - O-A5j Z
Address: 1 5) Oj' $w ( oC5, c.A
City: C-� State: FZip: 33 15-t
Qualifier Name: 0.5 C,�Phone#: 8� ' 35 5 GKo
State Certification or Registration #: G_ R Ll BC-_1P_) Certificate of Competency #: 12 c oo o (4 ?, Z
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: OUVIeAS Ii1caA�nR _
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ `lf i Gab CCF $ CO/CC $
Scanning Fee $ 3• d�J Radon Fee $ DBPR $ Notary $
Technology Fee $
Training/Education Fee $
Double Fee $
Structural Reviews $
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $ 7;v .�
BondingaCompany'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 issued. in the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of au t41F 20 (b by
-L��>a ��—�w�hooisis personally known to
me or who has produced JEL71AIVE 1 LLMNSk--as
identification and who did take an oath.
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
/ 3 day of —41AJe 20 ZA by
0,51*.4AJ1 Go�lL4�; t V r,4 , Who is personally known to
me or who has produced li/tlp-1-rzlez fir as
identification and who did take an oath.
NOTARY PU I NOTARY PUBLIC:
Sign: Sign:
Print: �� IQWL�� Print: =�
Jew�s " I
Seal: 1pWPue, Notary Public State of Florida > Seal: I .�t1 0��� NotetyPubft
Sindia Alvarez : " State of Florida
yY�cS3. < My Commission FF 156750 My commission Expites05120120t7
IF F"�04P Expires 0910=01 a Commission No. FF 11$81
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APPROVED BY Plans Examiner
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Zoning
Structural Review
(Revised02/24/2014)
Clerk