MC-09-19-2094 i i r ill
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� 5`�N E.1 A 'ami Shores,Florida 33138 �,�.
`� �N.� 4 e �0 4 ax:(305}756-8972 `'
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� � �s��r Permifi EV�e� �"� �-
PERM1��1�P�LICATIC}N sub�ermit �va, �� �� �� ��T�-�'��e � �
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(�BUiLDING � ELECTRIC � RUC�FIt�G REVISf�N � EXTENSIt�N � L
�PLUM�ING � MECHANICA! [�PUBLlC W(�RKS [� CHANGE tJF � CAN�E�LATIC�N (� SNf�P
CQNTRACT'OR DftAWINGS
!OB�4D�RESS: � � P�
Citv: Miami Shares County: Miarni Dade Zi�:
Falio/Parcel#: (s the Building H�starically Designated:Yes NO
Qccupancy Type: load; Ganstruction Type: Flaod Zone: BFE: FFE:
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C1WNE(2:�lame(Fee Simple Titlehalder);� ���'� �¢� �.�'p� ��`��� � � Phane#: ���,�� " �'�� �` �� G���� �
Address: � `�'.i�� t� r'�.. "d
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� �City: ��!� i�� r � t���� State: � Zip;
Tenant/Lessee Name: Phane#:
Emaii:
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C�NTR� � :Cam� ny me: �� Ph�ne#� ' � ��� _`���F `�
Address.
City: � State: Zp; �� � �
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Qualifier Name: Phone#:
State Certification or Registratian#: � �` Cerfificate of Competency#;
L7ESI�NER:Arehit�et/Engine�r: Phc�ne#:
Address: City: State: Zip:
Value of Wark for this Fermit:$ ��k� Squarejlinear Foatage of Wark:
Type of Wark: ❑ Additian ❑ Alteratie�n ❑ Rlew ❑ Repair/Replace ❑ DemaEition
�estriptian of Work: $���� �-{��a� �ut�� ���' G,c���� `� ��� �'�� "�"�-a �,;� f #c`� �t��� � �����``�
.�"`�`�� ����-F.�"� �� �"�i t� �1�� C''�'�"' t;a i��� 1� � ���S (�� � �—r
S eci �olor of��f�r fihru tile.
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s��m��a'E�e$ �''�'�'�"'"� Perm�t F�e$ ccF S colcc S
Scanrting Fee$ Radon Fee$ DBPR$ Notary$
Te�hnofagy Fee$ Training/Educat�on Fee$ Double Fee$
Strc�ctural Reviews$ Bond��
. � ._��.��
T4TAL FEE fVOW DUE$ "�4
(Revisedd2/24J2�14j
�ondin�Company`s Nam�(if appficable}
�ondin��ompany`s Ac3dress
City State Zip
Moi-tga�e�ender's Name(if applicable)
M�rt�ag���nd�r's�ddr�ss
City Stat� Zip
Application is h�reby mad�te�cabtain � permit to do the�ork and inst�llati�ns as indicated. I c�rfiify that n�wrc�r�C ar ir�stallat�on has
commenced prior to the issuan�e of a permit and that ali work wilE be perf�rmed to meet th� standards c�f all laws regula2ing
construcCion in this jurisdictian. I understand that a sep�rate permit must be secured for ELECTRIC, PLUM�IM1IG, SIGNS, POOLS,
FURRIACES, BQIIERS, NE�TERS,TANKS,�IR CONt�ITI��tERS, ETC.....
OWIVER'S AFF{E?AVIT: 1 eertify that all �he f�re�c�in� inf�rrn�tion is accurate and that alE work wilE be done in cc�mpliance with �il
appiicable laws regulating construction and z�ning.
" AE�NING T NEFt: Y UFt FAI�URE TQ R�eCARL� A lVta►TI�E t�F � ENGE E T A,Y
�tESU�.T IN Yt�l�Ft PAYIN� TVtfECE Ft��t IIt11P�QVEMENTS TQ Yt�UR PRC}RERTY. IF Y(}U INTEND
TO Q�TAI(� FIN��lCIIVG, ��NSl1�T iTH Y�I�R lElVDER OR AN �TTQRNEY BE�QRE RECQR�ING
Y 11 TI�E F C EN�E ENT."
tVottce tcr,4p�aGcant; .4s tr condition to th�issuanee of a burld�ng permit with an estr`mated vaPug exceeding$25QQ, the a�aplP�ant mcrst
prc�mise in goad faith tha�t a eop�of the notice caf ccrmmeneerz�ent and eorrstruction lrera law brachure wi/t be deliuered tcr the person
whose,�raperf}a is subj�ct ta attachrrrent. ,41sa, �r certified copy o�th�r�ce�r�ded n�trce�f commencerr�ent must be posi�ed at the jcab sit�
for the first inspection wrf�ich oceurs seven (7J dcry� after eh� tauilding permit Fs issued. fn the a6sence vf such �aosted nc�tiee, the
inspectian will nat be a�provet�and�r r�inspgction fee wfl/be charged. �
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Signature �� �"' � �"`r�� �°""�," 'i � . �.�. � M�. Si�naCure �
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C�WNER ar�0.�ENT � CONTRACTQR
The f �going instr ment was acknc�wled��d bef�re��this The regc�in�instr ent w�s aeknowledged before me this
day�f � 4�� ,20 ' by � day of � � 20 � l by
., ; �. �_ . .. .
� , ������� " whca is p�rs�nally kns�wn ta � � "� ho is personally knowr�t�
me ar vvho has pr ced� �'� ���� �,t[� < as me c�r�vho has produeed as
identification and ho id tak�an c�ath. identificat on nd who did 2ake an oath.
NOTARY PU� C: NQTARY P Lt :
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PrEnt: � �'�y a������ `t `��'�• Print: �.�..°�- �p"CA
Seal: �� ���t,,�� �.� � Se�l: � �, P���1� ��P �
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APPRC?VED BY ! Pl�ns Examiner Zanirtg
Structural Revieur Glerk
(Rev�seaaz/2a/zaz�)