REV-19-2977 (2)dBUILDING
PERMIT APPLICATION
UILDING ELECTRIC
❑ PLUMBING MECHANICAL
Miami Shores Village E^Er"kED
Building Department DEC 19 20
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 C2%r
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 201'7 X
Master Permit No.<fC (!�)3 � 9'6�
Sub Permit No. 11— 1� -J9 --2I��
ROOFING VISION E EXTENSION F7RENEWAL
❑ PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: l IZ3 NE 2. kC_
Folio/Parcel#: 11 -3 Z Oto b ) 5 V 7— � Is the Building Historically Designated: Yes NO
Occupancy Type: Load: [Construction Type: Flood Zone: �BFE: FFE:
OWNER: Name (Fee Simple Titleholder): i ot -i a3 �E gt Phone#: 30 _q -tct _6t C!�-k C-k
Address:
City: ;� State: r Zip:
Tenant/Lessee Name: 11-'e' ho! O'Ne + 'e ��c. Phone#:
Email: ',Y ahrl C) +kAn -- Ch; s5`, Ara - be.ace. , a,,e:t
CONTRACTOR: Company Name: 'S��T tiS ()C'%�\J. Phone# 3 7
Address: Ig11 k rQ kU&c= -e �m L�
City: - State: T L Zi
Qualifier Name: Phone#: _
State Certification or Registration Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#: _
Address: City: State:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New rr(❑ Repalir/Repl ce
Description of Work: �.. �� Glid
6 t-0�� e_ p�QGYnn�w.7� l c
p:
Zip:
❑ Demolition
I.
Specify color of color thru tile:
:wp�t't qAt
Submittal Fee $ Permit Fee $ CCF $ CO/CC'$
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 103. 00
(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 atta ment. Also, a certified copy of the recorded notice of commencem nt must be posted at the job site
for the first inspection which cc rs seven (7) days after the building permit is issue /n the ab ence of such posted notice, the
inspection will not be approve, an a reinspection fee will be charged.
Signature Signature
c.�or 9'1ta W6k&
� LLC
OWNE AGENT CONTRA R
The foregoing instrument w ledged'beforeb his The foregoing instrument was acknowledged before me this
�� day of 20 1`j by day of ,I/R 20 by
A. C-7c! who is_personally known to � 11 �+ , who is personally known to
me or who has produced �as me or who has produced C�z Vt�(L as
identification and who did take an oath.
identification and who did take an oath
\0%%4Ri111B1/�1
�j
NOTARY PUBLIC:
NOTARY PUBLIC:
����`� :''�LVEA;�
.
Sign:
Sign:
Print: L-Q,�,,., �.n.M` f `. �e 7
Print:
Seal:
Seal: '�ri.-,?°".;'o':?•o',���..
N140 Public State of Florida
`'Frf.=: r�•'Li���', k\4t
�i9si1RE"`R��
Leslye Chirino
MY COrn fission G�pG 1357
******** * 4 k*s** *s* 1*3 0�r#****.W**********************************************************************
APPROVED BY l 3l W Plans Examiner Zoning
l
Z/ C Structural Review
(Revised02/24/2014)
Clerk