REV-18-1896 (2)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
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
RECEIVED
JU(13 Tp1tla�
FBC 201"7
Master Permit No. _C\J L 6-� 1
Sub Permit No. P.(V � I a �0
M REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING [ifMECHANICAL ❑PUBLIC WORKS []CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: —1I 0 NE CIS_
City Miami Shores County: Miami Dade Zip: 33138.
Folio/Parcel#: I I. 3,20fo' Oly • 1C0 ID Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ?Gtul tt . c �vt Phone#:
Address: " 110 r at? Sfir e e k
: 1 C City,0," c I trGS State: T__L Zip: _391
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: f'[lr e S �-�. LPL Phone#:
Address: LEA B N W 13 3 SAruer
City: Op,1- LAC k a State: _ Zip: 330Sy
Qualifier Name: RNy42Q u:C Phone#:
State Certification or Registration #: cAe_o.33s!44 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ �� •� Square/Linear Footage of Work:
Type of Work: ❑ Addition
Description of Work:
❑ Alteration ❑ New . ❑ Repair/Replace ❑ Demolition
Specify color of color thru tile' ;.
Submittal Fee $r Permit Fee $ lv ' w CCF $ CO/CC$ '
Scanning Fee $ "l , Q Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $ _
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State Zip
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) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be annroved and a reinsnection fee will be charaed.
Signature
OWNER JI'Vi4i /r, I —
or AGENT
The foregoing instrument was acknowledged before me this
13 day of � A4 20 1' by
�t�n —f
_T� • who is personally known to
me or who has produced C> oh -(i (g as
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
_�d/ay of �1 u k&A , 20 1' by
R'psi V A?!I 4 2_ who is personally known to
me or who has produced b)_ 6v+ (� Lt as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC- NOTARY PUBLIC:
Sign: Sign:
• ( s
Print: Print: �J
Seal: 1 4�¢i�,6r Swap . Vasquet Seal: ��, Su4 T. asquez
_ Commission FF942611 =a �= Commission # FF942611
��`.. Expires: December 9, 2019 "= Expires: December 9, 2019
Bonded thru Aaron Notary OF W Bonded thru Aaron Notary
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APPROVED BY V PI/a/nssiExaminer Zoning
Structural Review Clerk
(Revised02/24/2014)