REV-19-2628Miami Shores Village RECEIVED
Building Department V 04 2919
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 BY -
INSPECTION LINE PHONE NUMBER: (305) 762-4949
i Gl - I�(Z FBC 20
��� - O� Master Permit No.
BUILDING - � 0-r(�f'- 2- �3
PERMIT APPLICATION Sub Permit NoPq' O
J- I (- l� l " 2 (o2-91
❑BUILDING X ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: lZS- Nt Q I 77VnACt
City' Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1/ - 3a0 S -o o 1 - 055 t' Is the Building Historically Designated: Yes NO _
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): hc2E 6 1" gA0,vN u 04,+hone#:
Address: /.ZSu Ak 9 /
City: /Vuam'
Tenant/Lessee Name:
Email
State:
p:
CONTRACTOR: Company Name: 066 V l , C Cw-'r-C Phone#: 305- 725- 6051
Address: 1 k/ ZQZ �E/lLACE
City: State: 1W Zip: '-2i 3 3.
Qualifier Name: �i OL /�jJE Phone#: 3e5- 7145-6057
State Certification or Registration #: 6C / 3OV a 3 / 3 Certificate of Competency #:
DESIGNER: Architect/Engineer:
hone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
r
Description of Work: oNi)rN(; 0� SIN Sl-%Zr I tAlEdRm ? fin Ern �ti`Gia
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
DBPR $
No ary'$
Double Fee $
Bond $
(Revised02/24/2014)
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 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 budding permit is issued. In the absence of such posted notice.. the
inspection Will not be approved an a reinspection fee will be charged.
Signatur Y I U k Al+. V
i OWNER or AGENT
The foregoing instru ent was acknowledged before me this
�J day of C)ZTy�Aaf , 20 15 by
ITon„P30f 6AV*0. ` who is personally known to
me or who has produced as
identification and who did take an
NC
Sig
Pri
Sei
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
1 day of �`�'x�� 20 15 by
0AV%0Qoltti,- who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PU
Sign:
Print: /
Seal:
os
as
JOFl� aG g77354
. MYg, Jucn 25, VSwvkes
W40 g�getNakarY
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APPROVED �m� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)