REV-19-2927 (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
ENTEnED
DEC 1
BY:
t RIVk
FBC 20ti`�
Master Permit Nol�c — d 4 - �9 - ��J1� v
Sub Permit No�cy_42_19 -G-1_�I2"T
j (REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /J� /" / tJ Ta�
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):_ �Vfi�i v ft-tZ11VL:01 Phone#:
Address: �3 D AJr 9 i
City: � (�y� State: Zip:
Tenant/Lessee Name:
Email
hone#:
CONTRACTOR: Company Name: W11& V/'r �t J 1 frVei711/j Phone#: 431�''
Address: CXV 5e A'.)
City: J-4 1 State: � L Zip: —33 17 Qualifier Name: Qwyq rz— % �-/¢IJ b'Phone#: % E6 %— ff^ rS d D
State Certification or Registration #: C 6 C` / S^ /S3 21 Certificate of Competency #:
DESIGNER: Architect/Engineer:
hone#:
Address:
City: State: Zip:
Value of Work for this Permit: $
Square/Linear Footage of Work:
Type of Work: ❑
mmm
Addition Alteration
❑ New
❑ Repair/Replace ❑ Demolition
Description of Work:
ti �7'�N
F ,�"ten
7 t Tr ° �S
Specify color of col&thru tile:`
Submittal Fee $
—'Permit Fee $'tea
r• • 'f
CCF $ ' " ""^ CO/CC $
Scanning Fee $
Radon Fee $
DBPR $ Notary $
Technology Fee $
Training/Education Fee $
Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ !!�j
(Revised02/24/2014)
r-
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 th ' site
for the first inspection which occurs seve ays after the building permit is issued. In the absence of such poste not, the
inspection will not beQpproved and a re' spec on fee will be charged. �-�
Signature,
Xv ff Signature (VI)
7 OWN or A G E N -` CONTRACTOR
The foregoing inst entt w s acknowledged before me this The foregoing instrument was acknowled ed before me this
day of / MF3 ) 2 20 (� by ` day of 20 by
who is personally known to LN-4A" v t�� Who is personally known to
me or who has produced -V L—TDA24 (lam UPEN�s me or who has produced ��-Zi'r�k�- N� as
identification and who did take an oath.
NOTARY
Prin t--j ({'' "--R>
Sei SINDINALVAREZ
MY COMMISSION # GG 238273
EXPIRES: September 3, 2022
Bonded Tt6 Notary Public Undwwftm
• :FOF F��•'�
#################
APPROVED BY
identification a who did take an oath.
AZ" _.
NOTARY
Print:
Plans Examiner
Structural Review
My C0MM►SMOO 0 GG 238273
ORES:September3' 2n
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Zoning
Clerk
(Revised02/24/2014)