WS-18-1741BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
Miami Shores Village RECEIVED
Building Department JUN 26 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ^ 1
Tel: (305) 795-2204 Fax: (305) 756-8972 �1/1
INSPECTION LINE PHONE NUMBER: (305) 762-4949
- , r.r FBC 201
} - _jL L% Master Permit No. V-� S
Sub Permit No.
❑ ROOFING ❑ REVISION ❑ EXTENSION �VENEWAL
[-]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /00/0 A E I ST 2T_ A.r
City: Miami Shores County: Miami Dade Zip: 33 1 3 d
Folio/Parcel#: IN-3ZO to - 013 - 14C41 Is the Building Historically Designated: Yes NO
Occupancy Type: ?_e5 Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): CANC1 Gt Vile I Phone#: 932 -"7`77 -7YU
Address: l 6a10 1-)E 1 s� Ave
city: M%A(V\ � SHc-�S State: zip: 3313 91
Tenant/Lessee Name:
Email
CONTRACTOR: Company Name: rb Pl2E�\S1CjN f, Phone#: -7?S- - 14'757(?3 1
Address:
12Z45 SW IZ2T11;r
City: M11gr l L State: FL- Zip: •3-3 I �O
Qualifier Name: 1 O «-\--\ 1q rh W A UC> igN Phone#:
State Certification or Registration #:CeC l 3 36-7 -1Z Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: ` City: State: Zip:
Value of Work for this Permit: $ Z Y . �D Square/Linear Footage of Work: ) %Z
Type of Work: ❑ Addition ❑ Alteration ❑ New ki Repair/Replace
Description of Work: i Z9IacE 16 K -7 2 Lz 'E' 0�L
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Permit Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
❑ Demolition
CCF $ CO/CC $
DBPR $
Notary
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(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 a reinspection fee will be charged.
Signature .li4=r- ... Signature W &A(j ,rQ.�.In
OWNER or AGENT
The foregoing instrument was acknowledged before me this
ZS�N day of JIA N C 20 28 by
C-4"(�i1 c,E V 1E 1 QA who is rsonall wn to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign 1AI 1...1
....
Seal: �.40P L Notary Public State of Florida
Wlliarri Huntress
Cy My Commission GG 137785
J Expires 09/15/2021
APPROVED BY
CONTRACTOR
The S ,_Ong instrument was acknowledged before me this
day of JUNJ 120 Ifs by
W 1%--L-iACie% WAU *S0 , who' personally n to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal: r 1: WiNiam Huntress
c My Commission GG 137785
OF �d� Expires Den 5/2021
Plans Examiner Zoning
Structural Review
Clerk
(Revised02/24/2014)