REV-18-3762 (2)BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
viiami Shores Village
RECEIVED
Building Department DEC 26 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 (� I
. ;r. isua) i95-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
F C 2W1 -)
Master Permit No.
Sub Permit No. �� 6
❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOF
CONTRACTOR DRAWINGS
AB ADDRESS: i 1 1 0 0 L o O �K__��
City: Miami Shores County: Miami Dade zip:
Folio/Parcel#: 11 " 31 o I — G Z 3 — o3 ?O Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): C (+(Z1 SZ IR1J I_A*,� s5(_ Phone#: 307 _% Z — `31
Address: I -�5 1XA) to (D
City: IA BAWL I S I't•1T26-,5, State: `1- Zip: 331 w
Tenant/Lessee Name:
e#:
CONTRACTOR: Company laame� LWC• I d,� c� HDilu r-PrioneM
Adaress q )50 �cy =HV�
City: ")01M'+ 'M� AC /State: F � O ►� ` � Zip: � 012
Qualifier Name: � 0Se CQ I1Pe- 141OnSn Phone#:
State Certification or Registration #: G C 0 S t US-5 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $ 6
City: State
Square/Linear Footage of Work:
Zip:
Type of Work: L—I Addition ❑�IAI_teration
❑lNew
❑ Repair/Replace
❑ Demolition
`5 Description of Work: CG U�lm
Con nC GTor
de-6i l AHU rG(UCo,4t
o
Specify color of color. liki 616
Submittal Fee $ ...,Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $ Q
TOTAL FEE NOW DUE � / C4. co
(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 na.
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulatin.g
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 ana 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
.vhose 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.
signature Signature
OWNE NT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of DG/0 620 by �( day of 0C(0�)- 20 �g by �
C i } 2%t5 i Prt-1 �.�{L_, who is personally known to J Cl� FC�IR5 Prt0'5*� who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign: fe-q—.0 Sign: L-s
Print:v Ve-P_ e -?. Print: -I -PC-
Seal: ,•4PA-`r':,y ,•••
BETSY D. PEREZ
�+.
Notary Public - State of Florida
• : ; •
Commission # FF 1823BO
%y,,:•'
My Comm. Expires Apr 3, 2019
,.***** **�frFO��`yak**J�eddYrar9kllslioeN#Jabare#'*�
***
APPROVED BY /F-
1 4
(Revised02/24/2014)
Seal: "v''"'.,I• BETSY D. PEREZ
Notary Public - State of Florida
. • "e Commission # FF 182380
,ad+ My Comm. Expires Apr 3, 2019
Plans Examiner
Structural Review
as
Zoning
Cien,