DS-18-1183Miami Shores Village IRECFTVFD
11fv�. Building Department VYo3ZW8
�w 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 �.
FBC 20 k45
BUILDING Master Permit No. � ( 03 r ) f & 3
PERMIT APPLICATION Sub Permit No. -O-( 6
❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
p / q CONTRACTOR DRAWINGS
tV JOB ADDRESS: Iq E 13,,' g }
City: Miami Shores County: Miami Dade Zip: 33) 3
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name
(Fee Simple gTitleholder): / �G�!�C7 WA N-er Phone#: 3 `17Z01 0Y07
Address: 17 A%E 13--0f 6�
City: M-'4/►1 ; .SGo/is State: F/ Zip: 33 13 3'
Tenant/Lessee Name: Phone#:
Email: C tiQr, I es 1wa I Ter Q 4 f,"4: I. r ,ni
CONTRACTOR: Company Name: So UA A hi Asr..t• P iHL ZPL Phone#: `� 0' 8a0
Address:
City: AP
FL Zip:i—
Qualifier Name: H-4K4 Phone#:
State Certification or Registration #: e6c m Q/ rr Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
N �
Value of Work for this Permit: $ Square/Linear Footage of Work: 6GD.5 S
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: 114'tt_a ,pwJAt- t,�r�•�kwd-f �i
Specify.color of color thru tile: -
Submittal Fee $ CK�� Permit Fee $ !� `� CCF $ CO/CC $
Scanning Fee $ Radon Fee $ ODBPR $ W Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $9C _bp?)
-- �- = TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
r L.
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 tk,&7,
OWNER or AGENT
The foregoing instrument was acknowledged before me this
I day of 1474 V 20 (8' by
CA Ar la 6' 6" 1 t'2 r• , who is personally known to
me or who has produced FL do-,,C-S A Ylti SC as
identification and who did take an oath.
NOTARY PU
Print:
Seal:
Signature
CONTRACTOR
The foregoing instrumen as acknowledged before me this
d'ay of a 20 ��, by
who is personally known to
me or who has produced 4,4AYt- as
identification and who did take an oath.
NOTARY PUBLIC
Sign:_
Print:
August 20, 2021 1 Seal:
WfMREY CHAN
WIVIMISSION # GG136185
EXPIRES August 20, 2021
APPROVED BYk4j� Plans Examiner S Zoning
Structural Review Clerk
(Revised02/24/2014)