PL-17-23491~ Miami Shores Village RECEIVED
Building Department OCT 02 ppn
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 , �4
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 201q
BUILDING /� Master Permit No. '&12 —I " Z -4
PERMIT 1FAPPLICATION Sub Permit No. Q` 1� — 23� j j D
F-IBUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL
LUMBING 7 MECHANICAL ❑ PUBLIC WORKS CHANGE OF CANCELLATION SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS: ( 3 00 � q S�
City: Miami Shores County: Miami Dade Zip: 33 l3
Folio/Parcel#: t (^ 3 c_ OS�— (2,�120 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): C �� i 5 \��. �C��d-i Phone#:
Address: ,hoc) N-g q'f 54
City: 1�1 � �v� � S V"b-te.5 State: � ( Zip: t3�
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: G 40r ?"'A5 a s Cam 54 Phone#:
Address: 13`2 S S W 2 22 34
City: V" `� (d,y"\,\ State: Zip: 3-3
Qualifier Name: Mgt gwe\ A, Caro•.ovva, Phone#:
State Certification or Registration #: C t?G l psi c 7 2.1 _Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: T1 '6 �►� i tn-s�
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ �� DBPR $ � Notary
Technology Fee $ Training/Education Fee $
Structural Reviews $,
Double Fee $
Bond $
TOTAL FEE NOW DUE $ -13 G • 83
(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
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 reinspectipn fee will be charged.
'-OWNERtXENT
The foregoing instrument was acknowledged before me this
2 ` day of20 by
who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Signature��=
(/20NTRACTOR
The foregoing instrument was acknowledged before me this
day of � eA✓% ,& C , 20 J:�) by
I ial1P( 4. ClrVhhnwho i =personallyto
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign: A111-511h�
Print: ���j_)Itln/\ n Rogues Print:
��S S Seal: NOTARY PUBLIC Seal: q!� NOTARY PUBLIC
o�
STATE OF FLORIDA OQ STATE OF FLORIDA
a o
" Comm# FF946106 `:a� �a Comm# FF946106
s�NCE 19�� Expires 4/17/2020 NCE ties Expires 4/17/2020
************************************************************************************************************
APPROVED BY Lb Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)