REV-19-413 (2). i .
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: (30S) 762-4949
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
RECEIVED
F B 2 12019
BY:
FBC 20 C�
Master Permit No. (_ 1100 'f"
Sub Permit NO.W -A Z-1 l - 41 3
�EVISION
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
(� CONTRACTOR
JOB ADDRESS: � 2-1� y ��
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade Zip: 0?✓1�.> i�
Folio/Parcel#: Is the Building Historically Designated: Yes NO L,-'
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
Address: 0321 I- 43�
e#: 305. 455. t7t2a
City: �Al A"t1 5 U'v State: Zip:3135
Tenant/Lessee Name: Phone#:
Email: %3cgw-'mL' C6w1
CONTRACTOR:: Company Name: h , 1104& (` -Fdlalk /11,LL(9C'RM Phone#:
Address:
City: M /cjm State: : L Zip: ?J,3/ SO
Qualifier Name: '_5Cfj/0 D-Me if 65 Phone#:
State Certification or Registration #: C676 / CL Z % �/Z _Certificate of Competency M
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: c G1 (Sl C3�
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $_
Technology Fee $,
Training/Education Fee $
Double Fee $
Structural Reviews $
(Rev1sed02/24/2014)
Bond $
TOTAL FEE NOW DUE $ " i i 00
. , ,
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 Ca-
O ER or AGENT
The foregoing instrument was acknowledged before me this
to (� day of 20 \ 4 , by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: '���; IamW ~' Mull_ : Commission # GG082163
L*: " Expires: March 13, 2021
Bonded thru Aaron Notary
Sig
CONTRACTOR
Theforegoinginstrument was acknowledged before me this
vl i� day of %(,tifvct2% 20 1 cl by
slrA J 1pcf-t-I who is personp ally known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: _.
Seal: ? ��= Commission 0 6GO82163
Expires: March 13. 2021
,�,Qr' Bonded thrU Aaron Notary
as
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
i
(Revised02/24/2014)