REV-18-1892 (2)Miami Shores Village ��
Building Department JUL 13 18
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 1y:
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING KELECTRIC ❑ ROOFING
F�BC201") G
Master Permit No. Ins L `y I y - I" �
V
Sub Permit No. ff,V [ y I �_l Z
❑ REVISION ❑ EXTENSION [:]RENEWAL
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: —1I O NE G3 5-hre-C7 '
City: Miami Shores County: Miami Dade Zia•
Folio/Parcel#: O I LA • 14-10 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): u\ Phone#:_'*5•t}0(• •$QQ(•(
Address:-110 1JE C% ,-WC-e-
City: 14,4rylk 5Inzres State: T;;L Zip: 3 lM
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: & N�4";s Phone#: 1��p•3QJ �D���
Address: I'M03 SW 21D Tt✓Y4GG
City: WAyyi% State: VL Zip: 3t�S
Qualifier Name: �1 An DISC. o P-cy' C L Phone#:
State Certification or Registration #: E c_1$0o k':1 \y Certificate of Competency #:
DESIGN : Archite /Engineer: MAW CAyl r6f_--C-� -PPhhone#: 3 0Sr '7Y
AddressI.?—`.City:iM/A mil Sri�State: A. ZipTT 6 G
Value of Work for this Permit: $ V Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: S L--✓) r— I Try ` n t�►l�( �/�yj (fit 1��
Specify color of color thru the w
Submittal Fee $ , Permit Fee $ ftly,4049 CCF $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
FCO/CC $
_ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ l
(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 approved and a reinspection fee will be charged.
Signature
—OWNER orA T
The foregoing instrument was acknowledged before me this
13_ day of 20 i8 , by
�G l A • Calk-1 , who is personally known to
me or who has produced L_ on E U as
identification and who did take an oath.
NOTARY PUBL
Sign:
Print:
Seal:
APPROVED BY
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
3 day of 20 i g , by
Fy'G1r1 I & Q i�Gi'CZ who is personally known to
me or who has produced 1D L O,l _Fl 4 as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Z Print: S V Z
, g �:04/1 Su T. Vasquez ,,a,,,
y q Seal: ��..e�,�� , Suyaia T. Vasquez
? �'= Commission # FF942611 = `�= Commission # FF942611
Expires: December 9, 2019 Expires: December 9 2019
Bonded *hru Aaron No*. . .• >*°:
Plans Examiner
Zoning
Structural Review
Clerk
(Revised02/24/2014)