REV-19-948Oy-I°�=�1q$�\
VA
.
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
RECEIVED
A � 3 L219
5T+I
FBC 20
Master Permit No. a'G' S• l`j • IZ$g
Sub Permit No. 2E�p Oy - ) C1 - 9 149
❑ ROOFING 1P REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: \t o /pia am'T".
Ill\► Al 0
Ciri: Miami Shores County:
Miami Dade ZiD:
Folio/Parcel#: ��3^Ld�i Oli)r34 D Is the Building Historically Designated: Yes NO 7"
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): V'UAAXijgL Phone#:
Address: Owp /SWL qq 0=T'.
City: µ11.0.Al ►6ywW4/7 State: rot, Zip: Ti!W W
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: �i�idt�'D1°.J►.0.. 4:;�pAJA2TV-4-1`M VA-C Phone#: �'h� GjZ.Cj •ZD
Address: CJ!I Ay l�LAJ 4 200
City: 4-::)Dy-M i J _l State: r"L-- Zip:
Qualifier Name: —t-PNAJF-V_. Phone#:
State Certification or Registration #: GI G. to e,& Certificate of Competency #:
DESIGNER: Architect/Engineer: rAno" Grip Phone#: ,�L•—�
Address: i4 (p0 x1r, Gn7>as,,l City: = ,_I1hM I State: 1:'I- Zip:
Value of Work for this Permit: $ I-Opoom- o Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New hf
Repair/RelSt�ce ❑Demolition
Description of Work:-1—"(Z1` W� "
Specify color of color thru tile:=
Submittal Fee
Scanning Fee $
Technology Fee $
Structural Reviews $
Permit Fee,$
Radon Fee $
Training/Education Fee$
-tee
CCF$CO/CC$
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 1 S-3 • dJ
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State
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 I brochure will be dClivered to the person
whose property is subject to attachment. Also, a certified copy of the iecorded notice of co mencement must be posted at the job site
for the first inspection which occ rs seven (7) days after the building permit is issued. the absence of such posted notice, the
inspection will not be approved ar(4 a reinspection fee will be charged. I
AGENT
CONTRACTOR
The foregoing instrument was cknowledged before me this The foregoing instrument was acknowledged before me this
day of i 20 J1 by _ day of AA, /L 20 11 by
Ir►�j y'DI 1/eOE— wh erTsonally known 1444 C A44A.G,/ GA A&4 , who is persona;ly known to
me or who has produced as mp,or who has produced as
identification and who did'take an oath. ' identification, and who did take an oath.
NOTARY PUBLIC: 101NN11111 NOTARY PUBLIC:
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Sign: c or3,?o trO Sign
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PrintPrint: 2.4'2O�>
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Seal: WF UMV jo�� Randy Senci a�
Seal:
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•......•Q� `�� ESTATE OF
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APPROVED BY Wy Iv Plans Examiner Zoning
Structural Review. Clerk
(Revised02/24/2014)