REV-19-2876 (2)Miami Shores Village Err
Building Department DEC 04 2019
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY. -
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING
%e�V" 12' 1 L?- Master Permit No. ?, e —01_ �q_ 112v
PERMIT APPLICATION
Z Sub Permit No. L — o _
❑BUILDING ❑ ELECTRIC
❑ ROOFING gTeREVISION ❑ EXTENSION [-]RENEWAL
PLUMBING ❑ MECHANICAL
❑PUBLIC WORKS CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS ..
JOBADDRESS:— 41,1O1
/0.-I -\r--
City: Miami Shores
County: Miami Dade Zip:
Folio/Parcel#: C "\% pl:�'1
O Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
a r !�, J��a�v.�.j L,` ( Phone#: 9" -Cq( 1 - wz
Address: SA
City: To���'Par-V/-
State: CC1 . Zip: S%nO5
Tenant/Lessee Name:
Phone#:
Email: ?f1�l Cj.r.Q.-�z`% Q
Q (` - Gsrv� s►ni.e,1� A :3a=;-L 6.ram'
CONTRACTOR: Company Name: V
a (/ Lllnj ;A 6 Se t ild Phone#: 7r12 r, 3�T
Address:
City: 0411 t" I
State: Zip:
Qualifier Name: I tIc.-tom r
r
it c ;;Ez, Phone#:
State Certification or Registration #:
GG 0 p� O Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: 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: � ��
, q) �$A*-4
Specify color of color thru 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
(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
q
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. i
Signature Signature ,
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
2 day of i'� ��� 20 H by
Oao /\CAS—N i � j who is personally known to
The foregoing instrument was acknowledged before me this
day of bCC J\461y'- __, 201 , by
y ICADr ��t? �- who is personally known to
me or who has produced b/L as me or who has produced D/L. as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: (12 I!`' - "
Print: R0-`:A\ln A120�MDyti
identification and who did take an oath.
NOTARY PUBLIC:
Signy��F- `ter —
Print: i0&:9A</N AUAryxy?,
Seal: Seal:
o,•��r;"',, ROSALIN ALZAMORA ROSALIN :ALZAMORA;`o'er State of Florida -Notary Public =%State of Floriy Public: •- Commissio42544i� Commission M GG 242544* ',i�i�a, ppl�f** �''0"` Au ust 26, 2022 '��°i``� August2
APPROVE Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)