MC-18-702BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
❑PLUMBING 4MECHANICAL
Miami Shores Village
RECEIVED
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 MAR 19 2018
Tel: (305) 795-2204 Fax: (305) 756-8972 C
INSPECTION LINE PHONE NUMBER: (305) 762-4949
{�'
FBC 201q
CANCELLED Master Permit No. P- C,-10 -11 - 23 (e S
Sub Permit No. I " 1 k � Z
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 3-11-1 N I— 10 ".l r'A-
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO .
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ( &V f _ f V Pr WrOS4 Phone#:
Address: 37 -4 pp- ( V�-( Jar- I Y
City:
State: Zip:
Tenant/Lessee Name: Phone#:
Email: . I I
CONTRACTOR: Company Name: J (i �c„n� M-UC�GY►i C� (C%w s Phone#: Y(v &7 -q f 57
Address: SOUS tofldru
City: t--( B State: PL zip: 331`�0
Qualifier Name: ,Jo
(� Y(e) 4 o z "4457
State Certification or Registration #: Certificate of Competency #: I �-wl oVl�b 2 3
DESIGNER: Architect/Engineer: Phone#:
Address: r City: State: Zip:
Value of Work for this Permit: $ 3 'J Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: /V�C.W U(,�- tµcr✓C- ? 1¢ I L A-1 p-Cr. 1.
Specify color of color thru tile:
Submittal Fee ,$ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $ 3
TOTAL FEE NOW DUE $ _
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
Zip
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 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.
Signatur Signature
s
OWNER or AGENT CON RACTOR
The foregoing instrument was acknowledged beforef me this The fore oing instrument was acknowledged before me this
day of '►' l r Vh 1 .20 t by day of 7 20 U by
�Y �e �Ur� i %�1. 7�'3'p y ,Esper Ywh i na known to S hsonall known to
me or who has produced f- t �lX as me or who has produced as t
identification and who did take an oath. identification and who did take an oath.
NOTA UBLIC: NOTARY P LIC:
Sig Bt : "A" K. GONZALEZ` Sign: L --
i: 02 /
Print::F... P EXPIRES: November 2, 2020
Print:
Seal: ' Seal: w COMMISSION # GG 142111
DMS: January 7, 2022
•�os a ;P•' Bonded Th, Notary PuVx Urderimlem
APPROVED BY 7,1PIs Examiner Zoning
4 !
(Revised02/24/2014)
Structural Review Clerk