REV-16-2008 (3)BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
❑ ROOFING
LJU
FBC 20
Master Permit No. 1 � I ':� 3
Sub Permit No. MV If— 112 -08
REVISION
❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
J � �/ � P CO�VTRACTOR DRAWINGS
JOB ADDRESS: �� ,1 Y)
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO _
Occupancy Type: Load: Construction Type: _Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): )0� 0
Address,: A L �I-CV4-1
City: M E qL&, ( Siqp /%-,S State:
Tenant/Lessee Name:
Email
CONTRACTOR: Company Name:
Address: t I -? L V
City:
Qualifier Name: WIM
State Certification or Registration #: _
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $
Type of Work: ❑ Additio
Description of Work:
i i Klt,J
Skcr �wn5� h
O 8
( El Alteration
t ti wl ), h
VD Cf-% ]-o L-\
Specify color of color thru tile:
one#: o
p: 3-313-'
one#:
oe
Phone#-39" � (0 q /
Zip: 331 v)7
1 �36107
73 Certificate of Competency #:
hone#:
City: State: Zip:
Square/Linear Footage of Work:
New
tom% f0�
�-C
Submittal Fee $ Permit Fee $ -9s . ak) CCF $
Scanning Fee $ ::�: -- CK) Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
DBPR $
r/Replace ❑ Demolition
Liti4,v-
CO/CC $ _
Notary $
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'bb 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 rein fee will be charged.
Si r Signature,
OWNER or AGENT CONTRACTOR
TheffJJfoor�ree�going instrum nt was acknowledged before me this
lO' d of by
-3)hIX [tortswho personally kn n to
me or who/ns produced
on and who did take an oath.
Sign:
Print. I
Seal:
=o
a
***********
APPROVED BY
(Revised02/24/2014)
as
The foregoing instrument was acknowledged before me this
da of
who is sonally known t
me or who has produced as
identification and who did take an oath.
NOTARY PUB
Print: u
LORETTA COMES Seal: vsr,o LORETTA COMES
MY COMMISSION #tEE181658 �� MY COMMISSION #FEE181658
EXPIRES: MAR 21, 2016 EXPIRES: MAR 21, 2016
Bonded through 1st State Insurance °f Bonded through 1st State Insurance
Plans Examiner Zoning
Structural Review
Clerk