REV-19-1099 (2)Miami Shores Village C I
AY 5 019
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 713'y ---
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
c
Master Permit No. �L_ �--
Sub Permit No.'e�'
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: t�2 S N�� �a C J
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simole Titleholder): N &rk- H" Phone#: 5 / Y-
Address: 1k5_ A�F_ �3��
City: k"N—, lo e S State: (-L Zip: 3 j fy
Tenant/Lessee Name: ( Phone#:
Email: N l-1 Krf'i�cIL�41�5R!!IN)�C'?-tr C_U IN
CONTRACTOR: Company Name: [--- 1tL L, L: �r� ,- Phone#: �� ✓�27 ` y/2((�
Address: SW A-w,
City: L�„p' State: F'V Zip:
�
Qualifier Name: l�o��i- , 1 ir 71t'/\ Phone#:
State Certification or Registration #: 13tits 13 Certificate of Competency #:
DESIGNER: Architect/Engineer:
hone#:
33K
Address: City: State: Zip:
Value of Work for this Permit: $ — Square/Linear Footage of Work: 2. Su C 5E
Type of Work: ❑ Addition
Description of Work:
❑ Alteration ❑ New
❑ Repair/Replace ❑ Demolition
WA
Specify color Vlor thru tile:
Submittal Fee $ Permit Fee $ _ �V ` L7� CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ o L v
(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
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) da er the building permit is issued. In the absence of such posted notice, the
inspection will not be apAroved and a reins ion fee will be charged.
Signature
or AGENT
The foregoing instrument was acknowledged before me this
day of _ 20 (I , by
, wh erson known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
as
Signature
CONTRACTOR
The foregoing instrument as acknowledged before me this
t'�— ` day of _ 20 19 by
b`XVi-07 yl dd'C/ who is personally known to
me or o s pr ced -,',J A v l t & rlS�,s as
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identific tion aid who take an oath.
yr'-•' .... , Ft0
N TAR PUBLICS `� • ,Gdt1M�.,
Sign:
Print: k 0 •::�� e n..a m�' t�_• P
Seal: :z w s u �: `� Seal:/�i'o�lgC p�c�`���
w4j ;+yam ry y,, c,N //, T 'r-���``\
e 7.
APPROVED BY bt Plans Examiner Zoning
Structural Review Clerk
(Revised 02/24/2014)