SGN 13-1657 9480 NE 2 Avejjo
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: BUILDING
V
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FBC 20
Permit No.T� ( �_ / W✓
Master Permit No.
ROOFING
JOB ADDRESS: C14 80 W.rz. �2"0 fw
City: Miami Shores County: Miami Dade Zip: 3 \3g
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO a Flood Zone:
OWNER: Name (Fee Sim le Titleholder): E"{sSic+t I .� Phone#: T8(,6''b4A gi z-F}'
Address: X'N O
City: 1Y'I:$. U100�rS•` State: 'E Zip: c3.0�j-O
Tenant/LesseeName: We . L��.L • Phone#: 301—J 9 ,('1Ag4
0
Email: t Vl l�), Q h-) O_I L . CO lkA
CONTRACTOR: Company Name: k Qa
Address: 5 la Z N Qv�_ 16
3o5-�218-3�I?
City: f1 o tci..yy\.. Stater i cO•Ci da Zip: 13 3 01 L}
Qualifier Name: Phone#:
State Certification or Registration #i Certificate of Competency #:
ContactPhon&:�� iOS htrQVII EmailAddress: 46Z@ FQStSigYls.Ct
DESIGNER: Architect/Engineer: N /,tR Phone#: rj 1.
Value of Work for this Permit: $� Square/Linear Footage of Work:
Type er. Work: ❑Addition -%-, lterati6n ❑New ❑Repair/Replace ❑Demolition
Description of Work:
Submittal Fee $�_ Permit Fee
Scanning Fee $
Radon Fee $
CCF $_
DBPR $
CO/CC $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
Technology Fee $
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
Application is hereby nkade 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 ELECTRICAL WORK,. PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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
RECORDIN' G. 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 nohee'of commencement must be posted at the job site
for the first inspec ' r which occurs seven (7) days after the building permit is issue . n the absence such posted notice, the
inspection will n t be ap oved and a reinspection fee will be charged.
Signature Signature
Owner gent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 57W
day of S� ( u�(J20, by/pt;(/)f>/ day of Mu 20/�, by�6/D SM',
who is pekk7kdo""nally known to me or who has produced who is personally known to me or who has produced_
As identification and who did take an oath. as identification and who d,d take an oath.
NOTARY PUBLIC:
Comm# EE118657
Expira6 811/2015
Structural Review
NOTAR IC:
Sign:
Print: cd/clR'Q� %�. CytiPJItj4AgL*
EDWARD P. OUNNINUM
f My COMMISSION 11 EE 880163
EXPIRES: May16,2017
(Revised 5/2/2012)(Revised 3/12/2012) XRevised 06/ 10/2009XRevised 3/15/09)(Revised 7/10/2007)