Mechanical Applicationi
t
t
Miami Shores Vi 11ag e
BUILDING
PERMIT APPLICATION
BUILDING
ELECTRIC
Building Department
10050 N-E-2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax (305) 75611111-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
ROOFING
Master Permit No.
Sub Permit No.
REVISION
PLUMBING RWECHANICAL 1:1PUBLIC"WORKS ❑C1iANGE
nNTRACTOR
F13C2 0 -
EXTENSION
W_ [JRENEWAI
CANCELLATION Q
SHOP
DRAWINGS
q4JOB ADDRESS: � ZI
Citv:Miami Dade NO:
Miami Shores County:
3ted: Yes
Folio/Parcel#: l�f� Y �f Is the Building Historically De ign�
BFE: �FFEOccupancy Type: Load: Construction Type:Flood Zone: �
OWNER: Name (Fee Sim leolder):`1 CI�I� phone#:.. C
Address,. � ipg q6ff mowdIIIIIIIIIIIIIII
_2iL3L
city: �a��i-. - Ci _zip:
Tenant/Lessee Name:
Email0
..
CONTRALTO
Address:
R,& Company Name:
�;47 j tm-oj
City:
Qualifier Name:
State Certification or RegiStration #0
DESIGNER: Architect/Engineer:
Address:_ O °19
Value of Work for this Permit: $_
Type of Work: AddItion
Description of Work: �
state:
VC.S.
State:
6 µ.oJ.Ls
r "I' IV
Alteration
I? _j 4-1 j f
Specify color of color thru tiled--
Phc)ne#:
-
rflrO %hone#:
Zip:aic-/ C� -
Phone:
��_Certificate of Competency#:
Phone#:
city. *% I 4. wn Ski State: dip: 3"3 j
Square/Linear Footage of Work:
❑ New Repair/Replace U Demolition
a -I oed r ft
-q-wfe4 4Pk//&d7*1n
Subm&al Fee $,,- Permit
fee Cfo/cc $.
Scanning Fee
Radon Fee $ Notary S
lion Fee �..� . �■ ■ DoUlAy. -�,
Technology FeyTrain ir�gEuc,
Structural Re%o MI
TOTAL FEE N ' �, 4 � i' f
fftevised02/24-
�o f
401SPIP, 47
Bonding Company's Nun@ lif Ippllcable)
Bonding Company; Addr*ss
City State Zip
"Ortgag* Lender's Nmms 0( 4pp11cable)
Mortgage Lendoe= Address
dEGENEWEEm-
City state
Zip
Application Is hereby made to obtain s permit to do the wor�C and installetien� as Indicated, I �rrtlfy that no wo►k of Installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards 01 all laws regulatins
construction In this jurisdiction., I understand that a soparale permit must be secured for ELECTRIC, PLUMBING.0 SIGNS, POOLS,
FURNACES, BOILERS, HATERS, TANKS, AIR CONDITIONERS, ETC,,,,,,, ,
OWNER'S AFFIDAVIT; I certify that III the foregolng information is accurate and that all work will be done In compliance with all
applicable ISM 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 ❑ condJClon to the Issuance of o bulldlnp permit with an estimated volue exceeding $2500., the applicant must
promise in gaod faith that o copy of the notice of commencement and construction fien low brochure will he deUvered to the person
whale property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the jobsite
for the first Inspection which occurs seven (7) days after the building permit Is Issued In the absence of such pasted notrce, the
inspection will not be approved and a relrrspecrlon fee will be rharped.
Signature
w�
y
f�
�� OWNER or AGENT
The foregoing instrument was acknowledged before me this
� n_ day of
_ rjfWA who is personally known
� or who has produced as
Identification and who did take an oath.
i Sisnature
CONTRACTOR
The foregoing Instrument was acknowledged before me this
� v
day of 20 �
�r s personally k#oo
me or who has produced as
identification and who did take an oath.
NOTARY PUBIC: NOTARY PUBLIC;
Sign Sign
Print: N «i _ qw/
Print: G r �• oil d•�
NOT��y pue�.�c �ea�: vaooe� ov u°spg qy i oa
Seal: rweg 4
rom%�M
STATE OF FLORlDA w saelS avm^d 4j"
. . Comrr� GG0&08i5
t9 Expires 12/27/2020
APPROVED BY
Plans Examiner Z o n I n j
Structural Review Clerk
v