REV-19-1100 (2)Miami Shores Village -c -1 ED
MAY 019
1 5
Building Department /
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY'
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No. '�'kvyJ
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL 110
PLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1,?-Z` V" 13 5 7
City: Miami Shores County: Miami Dade Zip: 33i�!5
Folio/Parcel#:I I - �)-0-�_ U �L? _ tZ 6 6 Is the Building Historically Designated: Yes NO
Occupancy Type: Load
OWNER: Name (Fee Simple Tit
Construction Type: e
er):� /vt
Address:
City: inM ; ��d c-�Gi State:
19
_Flood Zone: BFE: FFE:
P. ��n Phone# s; 3)2i 1
Tenant/LesseelName: Phone#:
Email: �Za},:t' n M
CONTRACTOR: Company Name: �� rl`, 4 E4F C C Ah-6, Lt i (i Phone#: 7 5-Y- z3 S '3d :� q
Addresis^:^-I �15��( s(,J �tj �ty
City: V V lr'L : I� State:
Qualifier Name: 4f a e_l C 2S P Phone#:
State Certification or Registration #: C EL 1 q )`r
16 Z I Certificate of Competency #: _
DESIGNER: Architect/Engineer:
Address:
Value& Work for this Permit: $
— U
ne#:
p:
State: Zip:
Square/Linear Footage of Work: 2 , � J Q
Type.of Work: ❑ .,Addition ❑ Alteration Elf�New
, ❑ Repair/Replace El Demolition
Description of Work: LG Lt o J 124 &
Specify color of color thru tile: (�
Submittal Fee $ Permit Fee $ _ " / . CCF $ CO/CC $
Scanning Fee $ .
Technology Fee
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 40. _
(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 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 absence of such posted notice, the
inspection will not be apprpvep and a reinspection fee will be charged.
Signature I
*tJ-R-`or AGENT
The foregoing instrument was acknowledged before me this
day of 4, 20 / l by
1—(L�crn who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: 1, r ✓' ,A .,nl -, J � L
7
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of �rT� 1 ,20 �l� by
SaO who is [,ersonally known to
me or who has produced it 'f I(aT1S'P as
identifi at n anwho did take an oath
f�OTA PUBLIC
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Seal: Seal: 1 ��� p�LIC°S�P�p``;
LISETTE CJIRRERI4S#tERN/WDEZ
J ��Z/hllIN1111N\��\
' MY COMMISSION 0 FF 974767
Tlw Notary Public Undw*dtnm
APPROVED BY ``� t- i //-)Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)