REV-18-3697 (2)Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC ❑ ROOFING
FBC Wjj (;�T-t-1//
Master Permit No��y la - ,_(0
Sub Permit No.M i8 - l
® REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING E54ECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 17� Is1 o too
City: Miami Shores County: Miami Dade Zip:3�
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
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Lf
OWNER: Name (Fee Simple Titleholder): � (s 1f t� '^ "-` � -Phone#: �05 I ' Z-� 3j3
Address: 1 ':7 lolp
City: N l ftmN State: Zip: :J3I1111;;�'(p
Tenant/Lessee Narne: Phone#:
Email
CONTRACTOR: Company Name: �%'��`' S &� K ��thi�-►��-�- Pho e# �
-^ v
Address:
.tom ( U '--V CST
City: IV I 'A ► ki ,,„„ State: Pk-- Zip: � 3 lc.
Qualifier Name: �� � S-P A L Phone#:
State Certification or Registration #VWC,[ �-'-%GI Z 0 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone
Address: City:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace
Description of Work:
Zip:
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ ( . , CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
I _ Mortgage Lender's Narrie (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 a nce of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signat a Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of 4by�"�, 20 10 by
�Ni1►�A,�—%�JS�t (ho is personally known to
me)pr who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
`'BETSY
D. PEREZ
Notary Public - State of FloridaCommission
zw
N FF 182380My
Comm. Expires Apr 3, 2019+t*
SAW *0ha a N*a%" "' ,- - 41
APPROVED BY
Vlks
The foregoing instrument was
acknowledged before me this
A day of �/-194 20 t 8 by
JQi rZ A AA" I , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
" • Commission #f FF 237118
Seal: �FOFFI�O,- My Comm. Expires Jul 7, 2019
°j"""•� Bonded through National Notary Assn.
Structural Review
Zoning
Clerk
(Revised02/24/2014)