REV-19-2400 (2)�3A \K)
BUILDING
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
PERMIT APPLIC TION
❑BUILDING LECTRIC ❑ ROOFING
CPIV)F,D
OCTI020119
BY: /�'
'jF�BC 20
Master Permit No. 1 1 VV--1
(7^ 9—z4Zz
Sub Permit No. V— 11 —'2100
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
CGNNTRACTOR DRAWINGS
JOB ADDRESS: I Lj iG'� �E5—(`� �— ` Rhc C:!Slk3(�
City: Miami Shores County: Miami Dade Zip: , 32;S-b •
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): — `� hone#: 7) Z — 3fl
Ad
Tenant/Lessee Name:
CONTRACTOR: Company Name
Address: _�'�
City:
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
L Cu >&O
p: ln)-� d
ne#: y 5�54 Z--.>,
Zip:
►tlL Phone#:
ficate of Competency #: _
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: El Addition Alteration ❑ New ❑ Repair/Replace El Demolition
Specify color of color, thr14.tile.c,-,
Submittal Fee •» �+" `T Permit Fie $:'"• t CCF $
,�...,F. - .. ,p..,.,,,�x. ,.'«: �., y•..ur n.....a'w'! oM.<:itif,+.W./9'en. r. f W+•r. �1•�. ,. �. oa..• � Scanning Fee $ y .,,�»r Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ _ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ `•r-3' M
(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
inspect;cr krill not be approved and a will be charged.
Signat Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument wa acknoow_l-edged before me this
I— day of Vc7N�` , 20, by
C\-s``(cs lmy\ ��Q, _who is personally known to
me�pr who has produced `-- as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: IL4 F
Seal:
CETSYACOSTAJOVINE
wtob on t GG 281530
ExOm April 3, 2023
r * * * r * * * * *'*�:�# * +lUr1►YIJr�ikIMWMIM
The fore oing instrument w s acknowledged before me this
day of 20 9 by
V e- ?- who is personally known to
me r who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
r) .- D
Sign:
Seal: w.., BETSYACOSTAJOVINE
i, Comakdon S GG 281330
EVWApd 3, 2023
APPROVED B Ir deGr/ Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)