BP-05-1099Miami Shores Village
Building Department �� � *4 C &
10050 N6LE0
.E.2nd Avees, Florida 33138
) 756.8972
BUILDING ,nnue,,
Permit Noek��'PERMIT APPLICATIO Master Permit No.
FBC 2001
Permit Type (circle : Building Electrical �p Plumbing Mechanical Roo in
Owner's Name (Fee Simple Titleholder) 1 l ` Vie Phone #
Own is ddress
City 1P k State Zip
Tenant/Lessee Name Phone #
Job Address (where the work is being done) ��(�/ Q,a 4ju 0
City Miami Shores Villa e County Miami -Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name �����V �C�L_ Phone #
Contractor's Address
City State Zip
Qualifier
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit:8 Square Footage Of Work:
A �=
_ N j0A SHA �T(0,
.. �• i . mm
G� V$.
Submittal FPermit Fee-$ �, Do iN� — CCF $ 6. GO CO/CC
Notary$ Jg/Education Fee$ 0-Zfl Technology Fee $ ��Scanning $adon $ Zoning Bond $
Code Enforcement $ Structural Plan Re $
e7j
Total Fee Now Due $ �\ r
(Continued on opposite side)
Bonding Company's Name (i
Bonding Company's Address
City
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 subjec o at7aa
nt. Also, c tified copy of the recorded notice of commencement must be posted at the job site
for the first in ti whi seven ) d s after the building permit is issued. In the absence of such posted notice, the
inspection will T app v reins ection ee will be charged.
Signature
Owner or Agent
Contractor
The foregoing instrument was acknowledged b ore me this. The foregoing instrument was acknowledged before me this
day of 20 by � K of 20 by
who i sonally known to me or who has produce who is personally known to me or who has produced
NOTARY
and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
Sign: Vpraas Sign:
Print: _ Co-:�:. esi0n A 3104 Print:
My Commidsion Expirgs 6,� 11otl d ' My Commission Expires:
Atlanflh,non R(:0., nc
APPLICATION APPROVED BY: Z 2J D�/
Plans Examiner
Engineer
Zoning
chc 05/13/03