PLC-18-3666i
Miami Shores Village N_KUh;1Vr_
Building Department D 12 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 n
FBC 20
BUILDING Master Permit NoT( 0,10
PERMIT APPLICATION CANCELVA
Sub Permit No.
BUILDINGELECTRIC ❑ROOFING ISION ❑
❑
❑
N ❑RENEWAL
]PLUMBING
❑ MECHANICAL
❑PUBLIC WORKS
❑ CHANGE OF
❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS:
J I Iy C
(05 � ui)
rt 1_ 5
City
Miami Shores
County
Miami Dade
Zia:
Folio/Parcel#:
1 — 7 Z 30 e OS ?2 —05 l�
is the Building Historically
Designated: Yes NO
Occupancy Type:
Load:
Construction Type:
Flood Zone: BFE: FFE:
13c e-r I 12
4 rJ`e7
Phone#, OV C 13 - 00 9 9
OWNER: Name (Fee
Simple Titleholder):
LI u •
Address: 1 5/
i de / 0 S
SP
City: �I a
M� Sh0 r e s
_State: �
zip: 33 ) 3
Tenant/Lessee Name:
Phone#:
Email: h • a I rDA611
CONTRACTOR: Company Name: Full SC r V i C e aI U m h nq Phone#: 9 S_Y aJ 2 7 3 5F�
Address: `1 G99 of q n9 b i kV-e
City: State: F I Zip: 3
Qualifier Name: TOIUI-er Andraol-,� Phone#: Etl
State Certification or Registration #: C F C I y 2 `? cl 2 `/ Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ % i Sb 3 • 00 Square/Linear Footage of Work:
07
Specify color of color thru tile:
Submittal Fee $� Permit Fee $
Scanning Fee $
Radon Fee $
❑ New
Technology Fee $ Training/Education Fee $
Structural Reviews $
❑ Repair/Replace
CCF $_
DBPR $
❑ Demolition
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 69
(Revised02/24/2014)
,kh
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
Zi
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. 1 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.
Signature Signature
OWNERASENT CONTRACTOR
The foregoing Instrumentwasacknowledged before me this
Z Off' dayof 20 I by
�¢ ►`• Al g.!L)n , who is personally known'to
me or who has produced FL ko --X as
identification and who did take an oath.
NOTARY PUBLIC:
The foregoing instrument was acknowledged before me this
day of /I ) f C_ 20 •" � by
c)y w 0, cc - , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 't J, 0
Print: 4lQ l A-
Seai:
Commission # FF 917472 Seal:
sa5xpires September 21, 2019 KARELIADUIZROMERO
R,F.,,. gods TW Tm4 Fd, VWX-4. eoo WW01i ' DIY C0WrIISS10N 0 00 262659
j Boded 11ru Notary t�u6ie iMide�wrhete
APPROVED BY �� ��- / Plans Examiner Zoning
(Revised02/24/2014)
Structural Review Clerk