WS-20-1331teMiami Shores Village RECEIVED
Building Department JUN 2 4 2020
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 SY:
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 '�"°
FBC 20
BUILDING Master Permit No.�? - 0-3- 4 l 3
PERMIT APPLICATION Sub Permit No. �V ���- " 331
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION NEWAL
(r /.-bbw —,q 066'^ �r
F_JPLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
t , CONTRACTOR DRAWINGS
N JOB ADDRESS: �05� 5 F_ 0 �D CD
City: Miami Shores i _/�� County: Miami Dade Zio:
Folio/Parcel#: 11 22 z�01 3 o (Ooo Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: n Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple
City: K i G M N s"b i e s state:
Tenant/L see Name: 0.
Email: 70(c�&Q�' SV V( r _ M �
CONTRACTOR: Company Name: Phone#:
Address:
City: State: Zip:
Qualifier Name: Phone#: _
State Certification or Registration M Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#: _
Address: City: State:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Permit Fee $
Radon Fee $
Training/Education Fee $
Zip:
❑ Demolition
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
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 COMMENUMENT." �--�
Notice to Applicant - IS a condition to th issuance of a building permit with an a (mated value excee ing $2500, t applicant must
promise in good f th that a copy of the a of commencement and with
on
lien low brochur will 6e deliveredo the person
whose propeAnItobe
subject to attachmen . Also, a ified copy of the recorde notice of commencem t must be posted a the job site
for the first =or
rs ven (7) days er the building per It is fss 1 ence of such posted)notice, the
inspection reinspection fee ill be charged.
Si
The foregoing instrurl nt wa ack edged before me this The foregoing instr r�nt w s ac ow died before me this
day of dd-�^- 20 --) y , by a; day of o� 20 (1 by
who is personally known to who is personally known to
me or 1ho has produced'L D% L as me or willas produced as
identification and who dh
NOTARY PUBLIC: I
I
Sign: a
Print: /rlsr
[y BARBARA MARIA RIOS
;ate' Notary Public - State of Florida
Commission # GG 310756
My Comm. Expires Apr 12, 2023
Bonded through National Notary Assn.
identification and who didtake
NOTARY PUBLIC: i►aY►u'•.,
ti?�; ,y\• `;
BARBARA MARIA RIOS
Notary Public - State of Florida
Commission A GG 310756
ry?oF�
My Comm. Expires Apr 12, 2023
Bonded through National Notary Assn.
Sign:
Print: ?.�4
Seal: Seal:
APPROVED BY t Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)