FW-18-1023oico�cki1 Miami Shores Village RECEIVE
Zs 20s AMIT
04� Building g Department p
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 SH
FBC 201%-{
BUILDING Master Permit No..� W 6 102-S
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I2OI A/E /00 157
City: Miami Shores n / County: Miami Dade zip: 3313S
Folio/Parcel#: ji3?_0500 0630 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Ll goAl geL%4E/Z Phone#:
Address:_ / 2Z01 /t/E 100 S %
City: Nt A MI SHOkES State: EL zip: 33 /38
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Phone#: _9,511, 12 DIOLQ
Address: l d '/ (o N V17l VQY�j)/C ,-3iiY (�
City: State: FL Zip: L33//�3,,//Z/ Z
Qualifier Name: /� �} �-7 AiYA Phone#: 95L/ W ` & 07
State Certification or Registration #: CL C D IID�5O / Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Add
Value of Work for this Permit: $
City: State: Zip:
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace. ❑ Demolition
Description of Work: —TO I—fx\eAo +
Specify color of color thru tile:
T
Submittal Fee $ Permit Fee $
Scanning Fee $
Technology Fee $,
Structural Reviews $,
Radon Fee $
Training/Education Fee $
CCF $
DBPR $
CO/CC $
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatu a �Signatu eA i 46�
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foreg Zing instrument was acknowledged before me this
/0 day of A P iz i u 120 19 by 10 •,�� day off A P RI L 20 1$ by
Li aut BF- LIJEE►'L , who is personally known to John Q IQ YI F who is p sonally know to
me or who h produced W 1V Ei2 L1 C.e n SE as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY P
Sign:
Print: c�CC
/`}N j---4d
Seal:p0►(01SS100 .
APPROVED BY
NOTARY PUB
\0,4�a L Riy,.�;%,,,,
Sign:
Print: 5ANi 4eA L • 2r
Seal: = �pm(p155100 #
%_ cP•._GG 11319: � _.
Plans Examiner
Structural Review
ing
Clerk
(Revised02/24/2014)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
SURVEY AFFIDAVIT
STATE OF (FLORIDA)
COUNTY OF (DADE)
14-.,e(4' 56- --
The undersigned Affiant, , does herebyattest that
(Property owner)
The attached survey, performed byA)VCN c 7z v leg u i ��s ,,rat CA
(Name of surveyor's company)
For address: 0,01 NAB 161> S�
Performed o(date of survey) is an accurate representation of the existing conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to
remove or obtain permits for any structures which now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of any such
structures may affect final inspections as applicable to this or other permits.
F her, Affiant say eth naught.
p6" erty Owner Signature Property Owner Print Name
SWORN TO AND SUBSCRIBED before me this 1 day of ") a 1'f
Affiant is personally known to me, produced <-- as identification.
M -=�
L.AWRENCE 8 COHEN
'z MY COMMISSION O FF901397
Revised on 5/22/2009/ Revised on 6/12/09 •a p+ +
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