REV-19-12196�
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Q4.0&.19-1219
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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
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
M 2 9 2�119
BY:
FpBC 20
Master Permit No. �- 6 1 f7 — 0 3 S
Sub Permit No. �v �S` 1 I A I q
Eg REVISION ❑ EXTENSION ❑RENEWAL
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: LM 0�- 91 3
City: Miami Shores County: Miami Dade Zip: J & )V
Folio/Parcel#: (�— 32 d (, — 0 t9 —UV � () Is the Building Historically Designated: Yes NO
Occupancy Type: Load
OWNER: Name (Fee Simple Titleholder)
Address: 9K te;u<A�
_ Construction Type: Flood Zone
BFE: FFE:
Phone#: SOS 582-�qBS
City: i��, 1 nil• CS State: t Zip: 3 �3
Tenant/Lessee Name:
Email:
hone#:
CONTRACTOR: Company Name: TA coy-e�-1-eto 5 Phone#: l SA
Address: 140 N � �-7 b }1 ^�
City: M lQ Vim( State:— Zip: �pJ12� q
Qualifier Name: CA- p OW /sj e Z Phone#: qs�
State Certification or Registration #: LCTL,S,�1 b 1 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
� .� r
Value of Work for this Permit: $ I (� 0P70 ✓=.eo Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New
i� ❑ Repair/Replace ❑ Demolition
Description of Work: 1 � �� 1 Cw i h l_d aCL,& 0, is
QCi n ss e S A qih �rCK ba o ou—
Specify color of color thru tile:'^
Submittal Fee $ Permit Fee $_ T ISO ' Q CCF $ 3 ' CO/CC $
Scanning Fee $ Radon Fee $ Z " �� DBPR $ 2 ' ZS, 'Notary $
Technology Fee $ S Training/Education Fee $ l Double Fee $
Structural Reviews $<—=;fQ' OO
Bond $
TOTAL FEE NOW DUE $ ` I • Q�
(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
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 be approved and q.fqios�qction fee will be charged.
Signatu
OWNER
The foregoing instrument s acknowledged before me this
day of ' i� r,-If 20 i by
X�yPdMwho is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PU
Sign:
Print: R t.CUcdo Go Za LZ,,
Seal:
P
*********** * yy,,F�
APPROVED BY
Notary Public State of Florida
Ricardo Gonzales
My CommissiorcGG 281457
Expires 12104l2022-
Signatu
The foregoing instrument was acknowledged before me this
2. day of /` (A.1 � 20 by
!ng 6-oAZtn IeZ-, who i r II known to
me or who has produced
identification and
NOTARY PU
Sign: —
Print: 11<<G f
take an oath.
as
Seal: +.d" Notary Pub"' State of Florida
Ricardo Gonzalez
My Commisswn GG 281457
of w Expires 12/04l2022
Plans Examiner W Zoning
Structural Review Clerk
*
(Revised02/24/2014)