REV-18-3754\� Miami Shores Village RECEiv�
Building Department 2018
� g p DECn�c �
L • 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 BY:
INSPECTION LINE PHONE NUMBER: (305) 762-4949 Q
BUILDING
PERMIT APPLICATION
❑BUILDING [JELECTRIC ❑ ROOFING
FBC 20
Master Permit No. E I1s -'�q VQ
Sub Permit No. {ENI 9 `.3�S "1
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑ PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
(�
` I CONTRACTOR DRAWINGS
JOB ADDRESS: G39 - ,y F_ "1 ' h � acc _
City: Miami Shores County: Miami Dade Zip: 33) 3 aR
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): e17j0M % ✓ t1kil?" lr Phone#: 3E71—461 JY77
Address: t377
City: irtit.L. ch ► cc State:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address: 9)5n O.A:)
City: T-4 r
Qualifier Name:
State Certification or Registration #:
iCl 0. (zip:
Phone#`�5�-i�
_ ertificate of Competency
DESIGNER: Architect/Engineer: Phone#:
Address: City: State
Value of Work for this Permit: $� ,,,��c� _ #0 • �0' Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration _ ❑ New ❑ Repair/Replace
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $
DBPR $
Zip:
❑ Demolition
CO/CC $
Notary $
Double Fee $
Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE $'q3. ego
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 issued. In the absence of such posted notice, the
inspection will not ke approved and a reinspection fee will be charged.
Sign
OWNER or AGENT
The foregoing instrument was acknowledged before me this
�
day of �e c-e—m b-e+�, 20 1 T by
9i C., Ww U L ibi44--k who is p onally known o
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
*************
APPROVED
(Revised02/24/2014)
R
The foregoing instru`men-,Vas acknowledged before me this
_ day of b10—Y , 20 1 Z by
who i rsonally known
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print
Seal:
**************************
Examiner
Structural Review
0AY 0?/�y :`0
N^.
N
Zoning
Clerk
Ltbu-ql -pl&,r
Miami Shores Vill
APPROVED
By
ZONING DEPT
BLDG DEPT
SUBJECT TO COMPLIANCE WITH AL
STATE AND COUNTY RULES AND RE
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