REV-16-2464C-1 /I q11 �
41-FRao
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
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
D
SEP 6 2016
3Y:
F BC 2014 �fih
Master Permit No. RC `' -tic(
Sub Permit No. �' \i (b -24 0q
❑ ROOFING IK REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS 1 b W 1 O Z 3
City: Miami Shores County: Miami Dade Zip: 331 5-
Folio/Parcel#: « 310 1 e> 2 O 3 b Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name'' (Fee Simple Titleholder)"
L1 K)102
Address: % W - 1 0 2 5�
one#: ;� 8(.� - 3,5� '1-i1-0
City:-gc" � S State: Zip:
Tenant/Lessee Name: Phone#:
Email: St1A4W1Ooa�OMl _
CONTRACTOR: Company NamE
Address:
City:
Qualifier Name:
State Certification or Registra
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit:
e#:
2
#: Certificate of Competency #:
Phone#:
City: State: Zip:
Square/Linear Footage of ork:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace \ ❑ Demolition
Description of Work: � L. C 0-4 )4 r'. %,� 0— a� �l tiv-� ,Jt CA
ip\
Specify color of color thru the:
Submittal Fee $
Permit Fee $C;' '0�) CCF $
Scanning Fee $ G . M Radon Fee $
Technology Fee $
Training/Education Fee $
DBPR $
CO/CC $
Notary $
Double Fee $
Structural Reviews $1�)Q - Q
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $ Jo
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 $2560, 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.
SignatqkUWW TM Signature
or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
010_ day offJ 'C 204____, by
,��� r` - •� , who is personally known to
me or who has produced L4 ci11ST, as
iden
NOl
Sign
Prin-
Seal:
APPROVED BY
(Revised02/24/2014)
.'011.1411,,YANADY PRIETO
'i�' __ MY COMMISSION # FF 214031
• •'a,= EXPIRES: March 25, 2019
_x •••••A,. . _d.dThruNotaryPublicUnderwriters
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 , by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
( Plans Examiner Zoning
Structural Review Clerk