REV-19-2653- ' Miami Shores Village � ` �IVMD
g �-, N V 0 42019
Building Department BY
1ItA
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING
Master Permit No. Ky'10 -1
PERMIT APPLICATION
Sub Permit No. q;kV ! I-1
❑BUILDING ❑ ELECTRIC
❑ ROOFING
❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL
❑PUBLIC WORKS
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
1 a
JOB ADDRESS: I � 5u de q
I ,� ett4jcc
City: Miami Shores
County:
Miami Dade Zip:
Folio/Parcel#: 3R05 - 004- 0
55,E
Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type:
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
hQC G q'4UWyj
Imm AV�1/ Phone#: 3d S-'G?- 865'_
Address: % 2<S0 A)C Q] $��tiAX
City: p. wpr' a�CS State:
Tenant/Lessee Name:
one#:
p: � 7/ -7A
Email:
4 n i
CONTRACTOR: Company Name: �t.L i �i� g 1'u f% 0,,-,ttt Phone#: I)L W-4u3 b
Address: I/720 2cA ytic Lag
City
i
Qualifier Name: nAukn Co
State:
State Certification or Registration #: C �C SSv
DESIGNER: Architect/Engineer:
Zip: 3W 31 `/
hone#: 3ui 317-eKil6
Certificate of Competency #:
one#:
Address: "I City: State
v
Value of Work for this Permit: $ Aj 41
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration PA71V
❑ New ❑ Repair/Replace
Description of Work: Sjvi)Cu r J-�vS n&C —X4 ry 0(7.A rt s cwCy
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $ _
CCF $
DBPR $
Zip:
❑ Demolition
CO/CC $
Notary $
Double Fee $
Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE $ '' 3 1 60
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
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 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.
JSignature Signature
OWNER or AGENT LC OR
The foregoing instrument was acknowledged before me this The foregoing instrun was acknowledged before me this
'T['� (+day of _Novi b�V1 � ejz, 20 19 , by �, ( day
j,,of'^ 1 r4JJ ih , 20 ) q , by
Jn n In l� 171Y11� , who is personally known to Id l �C� 7fn , who is personally known to
me or who has produced SQ I� as me or who has produced t T as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
C
�601/1'a &I"
Sign:
Sign:
GAle-2,
(
J
Print:
Print:
1
rzv -
Seal: w=.• %
DILEY R. GONZALEZ
MY COMMISSION # FF 962003
Seal:
SrzY`E
i
DILEYR.GONZALEZ
EXPIRES: February 26, 2020
_` •. <
MY COMMISSION # FF 962003
BondedT1xu Budget Notary Services
FOF
EXPIRES: February26, 2020
PLC?'
Bonded Theu Budget Notary Sens ce•
APPROVED BY
-—� �1
1� Plans Examiner
Zoning
Structural Review Clerk
(Revised02/24/2014)