REV-19-2645Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
REC�'��TED
NO0 5 ":'P'9
BY:
Tel: (305) 795-2204 Fax: (305) 756-8972{
INSPECTION LINE PHONE NUMBER: (305) 762-4949 J-R
FBC 20 a
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING MECHANICAL [:]PUBLICWORKS
k JOB ADDRESS: (2� 9 0 C ( 07- S� .
Master Permit No���
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL - Z� `
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip:
K Folio/Parcel#: Is the Building Historically Designated: Yes NO -
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �G{ ISO M c( ��_ Phone#: �l e6 B�
Address: � 02
City: (,.p rn f LO State: — Zip:
Tenant/Lessee Name:
wzimr
Phone#:
CONTRACTOR: Company Name `) a,, r l Phone#:
Address: i OO-1 cJ"
City: lft aa,. °l State: Zip: �� I
Qualifier Name:
State Certification or Registration #:
w�
C M C (Iso"3-�,1
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:
City:
Value of Work for this Permit: $ k (5-0 O Square/Linear Footage of Work:
Zip:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: l.)ev.. k X vt-,v �� a� v1c4 f-�► S
Specify color of color thru tile:,
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
Training/Education Fee $
CCF $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ I I6.330
(Revised02/24/2014)
4
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 a reinspection fee will be charged.
Signature Z 11 Signature
OWNER rAGENT CONTRACTOR
The foregoing instrument was acknowledged before come this
1 day of K) Qjq - 20 by
who is personally known to
me or who has produced 1
identification and who did to e a oath.
NOTARY PUflLIf�"-
Sign:_
Print:
Seal: ;• t MY COMMISSION # GG088579
,. '3EXPIRES April 17, 2021
The foregoing instrument was acknowledged before me this
day of t`;t��- 20 t q by
Q-A`ZL '5 (fARTIN0SU , who 41zrsonally kno o
as me or who has produced as
identification and who did to a an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: �►*' Notary Public State of Flonde
Alejandro Garcia
My Commission GG 167807
?.vw EXpiees 12/1312021
APPROVED BY lairs E aminer Zoning
Structural Review Clerk
(Revised02/24/2014)