MC-20-1465RECEIVED
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 By'
Te1• (305) 795-2204 F (305) 756-8972
JUt/I 0 2020
ax.
INSPECTION LINE PHONE NUMBER: (305) 762-4949 TO
FBC 20 l-�
BUILDING Master Permit No., ZC- D. ✓ 20
PERMIT APPLICATION sub Permit NoNo - b-� - 20 ') 40
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION VENEWAL
❑PLUMBING (i'MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
66 CONTRACTOR DRAWINGS
JOB ADDRESS: /O5Jr rJ /VG �0 Co,(
folio/Parcel#: % % -)-,;I Z./ jZ 3l 6 zW Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: �>
OWNER: Name (Fee Simple Titleholder): Phone#: -;;�
Address: S
City: Az*zlgeg, S State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:i f?-t
Address: / Y
City. Stat`ei Zip: 3 �d
Qualifier Name: Jyv, t '7 (' z P f? Phone#:
State Certification or Registration #: C�- / �! �(O �- - cl Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New j� 1� ❑�%R,ep it/Replace ❑ Demolition
Description of Work: �� — /l — /a — 3 Jr �a el Al / �QL 610-,<
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(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
City
Zip
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 t e ssuance of a building permit with an estimated value exceeding $2500, the a licant must
promise in good faith that a cop o t atice of commencement and construction lien law brochure will be deliver to the person
whose property is subject to att chm t. lso, a certified copy of the recorded notice of commence ent must be p ed at the job site
for the first inspection which ccu i e after the building permit is issued. n the a ence of h posted notice, the
inspection will not be approve an spection fee ill be charged.
Signature Signature
E ENT NTRA OR
The foregoing instrument s ged before me this The foregoing ' strYantwas acknowledged before me this
day of 20� by _ 2 day of 20 a-d by
who is personally known to A►'� L ► who is personally known to
me or who has produced '�L �— as me or who has produced �o as
identification and who identification and who did
tiRr Pos-. BARBARA MARIA RIOS
° �` Notary Public i►�r ° BARBARA MARIA RI05
NOTARY PUBLIC: _ ' rY blic - State of Florida NOTARY PUBLIC:.
Notary Public - State of Florida
er Commission p GG 310756 i �' Commission 8 GG 310756
ry' orc My Comm. Expires Apr 12, 2023 or A My Comm. Expires Apr 12, 2023
Bonded through National Notary Assn. Bonded through National Notary Assn.
Sign: Sign:
Print: Print:
Seal: Seal:
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)