REV-19-2793 (2)X
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
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
RECEIVED
NnJ 21 2019
BY:
fBC 20 �k
Master Permit No. z C _o7_lc(.—V12-o
Sub Permit No. M G —OS —1 � —�Z� I`)`,E! _ D93
E9-1VISION ❑ EXTENSION ❑RENEWAL
[--]PLUMBING
P4ECHANICAL [:]PUBLICWORKS,
❑ CHANGE OF ❑ CANCELLATION
❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS:
�1,
-/ % V 1 A/ 0;,' 4 "n%
AyF
City:
Miami Shores County:
Miami Dade zip:
Sy
Folio/Parcel#:
i ` 3 ?.176 -.-\ 3 Jq '1 0
Is the Building Historically Designated: Yes
NO
Occupancy Type:
Load: _ Construction Type:
Flood Zone: BFE:
FFE:
OWNER: Name (Fee Simple Titleholder): ST• r���h M al t-n , C Phone#: QSq r 1
Address: 10o, UJ. ,ik uwae �K,\J
City: Qd . NULL Da.r State: �i� _ Zip: 33
Tenant/Lessee Name: phnnAtt.
Email:
CONTRACTOR: Company Name: 8 1 �- S ��') E /h S F� i% I`�z- Phone#: 3 O .P 25 ZU n 9'�
Address: � �g W U 0 PC_
City: �-( I,t1 C,�1�� State: L Zip: 3 3 2
Qualifier Name: �� € V e ' t " T C/� Phone#: 3 0Sg2 6 gg-0—
State Certification or Registration #:CAG l ? 13 4?' Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
City:
hone#:
State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: n- E (.p LA-�- 1E A i N lx9 !4/(% Q (i 2 ~
" i'l /cJ i I
Specify color of color thru tile:
Submittal Fee $__ Permit Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
CCF $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $
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 on 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 N _ Sign
OWNER AGENT
CONTRACTOR
The foregoing instrument was acknowledged before me this The fbWgoing instrument was acknowledged before me this
day of N 20 1 !!1—, by —LO day of N O , 20 �, by
O.Md� ��2 _Awtho is personally known to :3--4 SA J it \diQIao is personally known to
me or who has produced as me or who has produced DL., as
identification and who did take an oath. identification and who did take an oath
NOTARY PUBLIC:�—
—
"""'. ROSALIN ALZAMORA
,.o�sY►�g.,
State of Florida -Notary Public
NOTARY PUBLIC:
,```"r'�''�. ROSALIN ALZAMORA
�'" ';
_State of Florida -Notary Public
�.�,.
-• •= Commission N GG 242544
's+�Fp��,F?.� My Commission Expires
,
Commission N GG 242544
My Commission Expires
g
Sign: �'j�, "'
Aupust 25, 2022
Print: PPUkIA
Print: .Cw
Seal: Seal:
`/� r/" Zoning
APPROVED BY fans Examiner
Structural Review Clerk
(Revised02/24/2014)