PL-18-312Miami Shores Village CET D
Building Department F 07 ors
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 LBY:
Tel: (305) 795-2204 Fax: (305y756-8972-*
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 C�
BUILDING CANCELLED Master Permit No.;?-Q 19—
PERMIT APPLICATION Sub Permit No. i- ( 8 —
❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
X-PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
10B ADDRESS:
City: Miami Shores County: Miami Dade zip: �3 I3Ga
Folio/Parcel#: ((- hut, ' i3 - 3 cl S o Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): aA4L"-f HAP-Ah L Phone#: a') `l Zct)
Address: rl_� 7 �'�✓� (Y S y7l�js- :i
City: IL I State: 17-1- Zip: �3 i
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Phone#: r
Address: � y�
City: % - State: Zip: ?
Qualifier Name: Phone#:`AOl'' _�✓�` ��
State Certificatio o egistration #:G�i`�lJ d Certificate of Competency #:
DESIGN : Archite Engineer: I v t AM,- A U— Phone#: � 0 ► -C,
Address:_ ! 9'- SL City: IMW1I Sid State:R- Zip: -�3 13
Value of Work for this Permit: $ I , J� Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Re air/Re
p place ❑Demolition
Description of Work: Uzf O✓0y �ycl jiN� � '( �Gc # % h-v✓�` j��r}7�11_C�?rL 'f
Specify color of color thru tile:
Submittal Fee $ ecz�) ' Permit Fee $
Scanning Fee $
Technology Fee
Structural Reviews $
Radon Fee $ co
Training/Education Fee $
CCF $ CO/CC $
DBPR $ • 4�) C5 Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ I I6
(Revised02/24/2014)
- ) -,jr,- -s • 4
Bonding Company's Name (if applicable)
Bonding Company's Address
City . u , 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 ' In the absence posted notice, the
inspection will not be approved and a reinspection fee will be charged.
c
1CSignature Signature
OWNER or At5IT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of %1 4i Z- 20 17 by
REN" 1-1 AA v &1C, who is personally known to
me or who has produced 0. t , as
identification and who did take an oath.
NOTARY PUBLIC: ,.Wy CHASE CAMPBELL
+r .: MY COMMISSION M FF 200055
'= EXPIRES: February 17, 2019
of Bonded Thru Notary Public Underwriters
Sign:
Print: C - C_j +rtlq bg Z- �-
The!f9mgoinginstrul ent was acknowledged before me this
day 20, by
j�)-
C who is personally known to
me or who has produced
identificafLon.and_who di
ARY PUBLIC:
Print:
ke an oath.
Seal: Seal: * * MY COMMISSION # FF 238149
EXPIRES: June 13,2019
�?r17o �op�F Bonded Thru Budget Notary Services
as
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APPROVED BY fPJ 2 - T7- I/ Plans Examiner Zoning
IF
Structural Review Clerk
(Revised02/24/2014)