REV-20-51Miami Shores Village
ENIPERED
Building Department
959- .2nd Avenue, Miami Shores, Florida 33138
el (305) 795-2204 Fax: (305) 756-8972
V9 010 N LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING 19ELECTRIC ROOFING
❑PLUMBING MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS:
JAN 10 2020
BY: rq---D
FBC 201-1� (0 k
Master Permit No. - 21 2.1v
Sub Permit No. t'T� \J- dm' 10-51
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type
OWNER: Name (Fee Simple Iitleholder): _ _ -X_) Jx A,i l V
Flood Zone: BFE: FFE:
J Phnncfk• �-"�
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Phone#:(• T-)o '" 00 3.T—
Address:ly� i� SG�J 13.5` lrYu /
City: ?!�Ayadl State: �� zip: 33/(914/1
Qualifier Name:
one#:
State Certification or Registration #: C-&11 J 140 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
Description of Work:
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $
DBPR $
❑ Demolition
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
Zip
City State 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 occu ven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved a d inspection fee will be charged.
Signa re Signature
0
NER or AGENT NTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of �[�f _ by 7 day of 60 Vq by
ho i personal)y kno n to ho ersonally know to
me or who s produced as me or who has produced ki as
identif hg o 9ftW identification and who did take an oath.
NOTA' 20, 2023
Muiah • ? 08201� NOTARY PUBLI
%VAmVaq
Sign: Sign:
Print: Print:
Seal: Seal: ^agmission 8
as
t4ina: MN -A 20, M3
Bonded Tina Aual f►
APPROVED BY �1L' ZdPlans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)