REV-19-2970 (2)vl� ENTERED
Miami Shores Village rE.-I 18Y
Building Department vxl
� IC
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 64A
FBC 201� �i
BUILDING Master Permit No. �C— -1 G�—I a '23"71
PERMIT APPLICATION Sub Permit No.yv--,4- I Z' I -2°110
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
(� CONTRACTOR DRAWINGS
JOB ADDRESS: q !1 OCo .jC' 2n4 hre•
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 320 6 — 01- 2?—M Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: B E: FFE:
jai
OWNER: Name (Fee Simple Titleholder): MIAMI 5r " - lct4 P on : ;i_
16
Address:
City: iYI) TAI V
Tenant/Lessee Name:
Email:
CONTRACTOR: Company ame:`rM V IAto
Address: PIS
City:00&!k;�Rlw
State:
Qualifier Name: Phone#: _
State Certification or Registration #: N CIO Certificate of Competency #:
DESIGNER: Architect/Engineer: `� Phone#: _
Address: City: State:
r-
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ AddiQtionl I❑ Alteration ❑ New ❑ Repair/Replace
c
Description of Work: ►1 �V I itl J6 .bl_ ��VA�t
Specify color of co,(or ru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $'
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 619 ,
(Revised02/24/2014)
"'rz 516 1
Zip:
❑ Demolition
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 osted notice, the
inspection will not be approved and a reinspection fee will be charged.
1
4ia
Signature Signatur �N
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of b2c 20 ��, by
who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
t.
The foregoing instrument was acknowledged before me this
1� day of 20J by
I Col .\ I nnAgfQIA , who is pers n to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: nn Sign:_
Print: r� mv% Print:
Seal:
###############
APPROVED BY
(Revised02/24/2014)
—ORIT MIMOUN
'Ay COMMISSION # G • 102406
EXPIRES: December 14,2021
Seal:
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Plans Examiner
Structural Review
EXPIRES°�., Q
—�
0
Zoning
Clerk