REV-16-1767f
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC
❑PLUMBING [)g MECHANICAL
Miami Shores Village
Building Department 11N 24 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 79S-2204 Fax: (305) 756-8972 BY:
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 201`1
Master Permit No. (O oil D
Sub Permit No. 1(O " n cP;q ,
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL Q�
[:]PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
JOB ADDRESS: IoLA Q W 10 Z
CONTRACTOR
DRAWINGS
City: Miami Shores County: Miami Dade Zip: 331 5-L--3
Folio/Parcel#:0 Z Z Is the Building Historically Designated: Yes NO J
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Phone#: - I CIO. 356 -
Address: I n'A Vj "'� \ (-=- Z Q +
City: SCAXW4"} State: -'FL Zip: @@3 1STy
Tenant/Lessee Name: Phone#: �U6- 3S6'
Email: �M �pob �V�� I ��-�•�
CONTRACTOR: Company Name: Phone#��DS
Address: 1 2 J w r 3� 54. ley 4!4 2 Z
City: "IL
Qualifier Name: C -�% 1 O
State:. Zip: 33 O
V-"�A 91'�' Phc(ne#: 30S) Z 3 S -COO J
r
State Certification or Registration #: C" C \ 2 y q a gS Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address: 4 City: State:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Zip:
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ . Permit Fee $ it b-P CCF $ CO/CC $
Scanning Fee $ 27-6 Radon Fee $ DBPR $ Notary $
Technology Fee $
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(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
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. CIF 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 $1500, 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
WNER or AGENT
The foregoing instrument was acknowledged before me this
�` !3 day of �) 20 l r by
~ � �, who is personally known to
me or who has produced t L Lkocn1 as
identification and who did take an oath.
NOTARY
Sign.
Print: �� 1A ��-
Seal: , epAyP&
***********
APPROVED BY
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
,X J� day of L'� 20 /6 by
C4W.WS �i.`eA)."EZ , who is personally known to
me or who has produced.6L. Dlzry-��'!fL�c /�Ls= as
identification and who did take an oath.
NOTARY PUBLIC:
Notary Public State of Florida T Seal:�6stISPiQnZ218i
Sindia Alvarez :° WotaiYPt�KC
My Commission FF 156750 State of Florda
Expires 09103,'2018M My C0nIn11SS10n FJcpIreS05i1012o17
Ctt�ission No. FF 11861
************************ **** *************
ans Examiner Zoning
Al
(Revised02/24/2014)
Structural Review
Clerk