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.