MC-19-69Miami 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
P\\-Z,v - 6�-19 -\4CID
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
L�-
FBC 20
Master Permit No. (42,- I --(� _L3 --)
Sub Permit No. /-U(— A —(O`1
U-06VIS10N ❑ EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL PUBLIC WORKS 7 CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: OAS Q C� fo 5�. rye
City: Miami Shores County: Miami Dade Zip: �8`r x
v
Folio/Parcel#: t1 ?�jZ>d 6 1 "1 a / 113 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �Cs.p 1�PT Phone#: 9DS-1 C5
Address: ( OS A. E 9!& ,
City: j11b ("L* sj' &c r C State: '�. Zip:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: � l
Address: ;� p1,'4�q -c,-w S't'
hone#:
Phone#: 5pyW— IYOG
City: State: E�c Zip:
Qualifier Name: I.f�Jc/`dI�uh/�2�2 Phone#:'YVl-1`(',
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Certificate of Competency #:
ne#:
Address: ,, City: State: Zip:
Value of Work for this Permit: $ >�0o Square/Linear Footage of Work:
Type of Work: ❑ Addition., ❑ Alteration [�] New ❑ Repair/Replace ❑ Demolition
.. .: Remgo• �•_ . Imo, ��- .ram
ln-a�
Specify color o color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ / 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
r"
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. 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
1212— day of 20 lot , by
G' who is personally known to
me or who has produced a OL— as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal: M Y COMMISSION # GG 199267
0",EXPIRES. May 30, 2022
Signature
CONTR CTOR
The foregoing instrument was acknowledged before
me this
day of �-r�,�vP 20 `7 by
liV who is Enally kno n to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
LUZ P. ERLICH
My COMMISSION # GG199267
EXPIRES. May 30, 2022
E-11
**********************************-�*G 7***)ef
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)