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RC-16-623Miami 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 I APR 0 5 8 FBC 20 Master Permit No. �C I Q) — (33 Sub Permit No. k I - 62-'3 ❑ REVISION ❑ EXTENSION [:]RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP n n' 2 CONTRACTOR DRAWINGS (� V JOB ADDRESS: - I i i' �_ qJ rd 'T k City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: '- fFl000dd Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): C it ar- ►j/e5 t-c� C7 Phone#: 3 �72. e-1 oybl Address: % l IVE City: &*41, J 4a/ e- 9 State: FL Zip: 3 3 113 $" Tenant/Lessee Name: - / Phone#: Email: CY1elr1e9 l r C���.a,' .Car► CONTRACTOR: Company Name: MC \ 1 W Y1 C Y Phone#: Address: City: Qualifier Name: State: p: ne#: State Certification or Registration #: Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: Ad Value of Work for this Permit: $, Type of Work: ❑ Addition Description of Work: City: State Square/Linear Footage of Work: Zip: ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition - Specify color of color thru tile: Submittal Fee $ Permit Fee $ V • 03 CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Structural Reviews $ Double Fee $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ T( L l 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. T� ^ Signature /(4 e�� Signatu OWNER or AGENT The foregoing instrument was acknowledged before me this -S day of A -PC " 1 120 1S by C it C) r �-C S a l -eY who is personally known to me or who has produced 1� f r V-eT I � C-ns-le as identificatio did NOTARY P rBLIC: \\ i Sign: Print: seal::'6y •, YANAD��( P IETO * * OMMISSIl9 # FF 21-1 a•:,�a EXPIRES: March 2 6, 2010 ?a wd:'� 8nnded iltry ibt:0' W+t�i6 �� APPROVED BY d4k a 1 CONTRACTOR The foregoing instrument was acknowledged before me this day of , 20 by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: Plans Examiner Structural Review as Zoning Clerk (Revised02/24/2014) Miami Shores Village 18 Building Department 10050 N.E.2nd Avenue I,VL Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit Owner's Name (Fee Simple Title Holder):__C Owner's Address: 7 G` City: 0*-1 •� )/'Ee•Phone #: State : ,,�L_ Zip Code; Job Address (Of where work is being done): �5 / NE ? 3 57 City: Miami Shores State:_Floricla Zip Code: Contractor's Company Name: Address: 1 Nm U C /V %.J 4- G Phone #: 3 ®1 4-� Y.!^ O S1 f 2- City: State: Zip Code: 3P/ 6 Qualifier's Name : Fi tt L. �4 �"' ,0O �F / ES / As Lic. Number: C C 2S Architect/ Engineer of Record Name: Address: City: Describe Work: State: Phone #: Zip Code: hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless of all legal involvement. Signature /(i!/iA, —K.✓ v Signature � Owner or Agent Contractor or Architect The foregoing instrument was aknowledged before me The foregoing instrument was aknowledged before me this S day of 20 ,by olvlt S 1vt, this S day of 7r� , 20►3 by r l O vIdO l �S� aS Who is personally known to me or who has produced who is personally known to me or who has produced Y 'er 1 ; hs-� as indentification. q-1 W. ( N as indentification. No ary ubli No ry ubli Sign: Sign: Seal: Seal: YANADY PRIETO a�Y PN. YANADY PRIETO rPr °�1F` :iR ' a MY COMMISSION It FF 214091 MY COMMISSION FF 21 AA31 EXPIRES: Maroh 25, 2019 a. EXPIRES' Mardi 25,1� w Ba�dedThruNMarYiubrdc7t+�d6tbr++Ge�S i �a Ftd ' Bonded Thru Notary Public Undervrritars ` ,,. Miami Shores Village Building Department 10050 N.E. 2No Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Change of Contractor/Architect or Engineer A change of contractor, architect or engineer must be done under a permit number., There is a $75.00 charge for a change of contractor. The owner will submit a Change of Contractor Form completed with notarized signatures. If the signature of the previous contractor cannot be obtained the owner must send a certified letter/return receipt notifying the previous contractor, architect or engineer the reason for the change. The owner must allow 10 business days for the contractor, architect or engineer to respond. A permit application must accompany the change of contractor form, with the information and signature of the new contractor. oThe ,new contractor must be registered with the Village or must submit the required documents to register with* the •Villagel' - 0. ' 1. Change of Contractor form completed, signed and notarized. 2. Permit application by new contractor. 3. Required fees. 4. Copy of original letter sent via certified mail along with the returned receipt. In addition to the requirements above the architect or engineer of record must authorized the new architect or engineer to reproduce his documents. The authorization must be in writing and must be signed and sealed.