PLC-18-3670BUILDING
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FrB��C 201� � b
Master Permit No�U���
PERMIT APPLICATION ANCELLWEVISION
Sub Permit No._
BUILDING ELECTRIC rp ❑ EXTENSION
[:]RENEWAL
*UMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: t S 11 of 6 IQS s 4UA It f—b
City: Miami Shores County Miami Dade Zip:
Folio/Parcel#: k � - 2 2 30 " 05 3 - 0540
V Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: 1 FFE:
OWNER: Name (Fee Simple Titleholder): %NDA k, NA i) 4- 4 i 01V Phone#: (30r) 7 7 3 -93�
Address: /O S ST
City: Mia,; Sh o re S State: FL- Zip: 33 / 3
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: FU/) S (ary I e -e P) U Yy�)Oi nQ Phone#: c%SN -3:) 7 bsg -a-
Address: 9 0 g MOO? N N 10-
City: hayif_ State: I Zip: ot, 1 '-4
Qualifier Name: T(a V 1C i fir\dl (a GI-f Phone#: pis & S/ a- c (_ 8 9 c)
State Certification or Registration #: C F C ) N 2 q q 7 -9 Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#:
City: State Zip:
Value of Work for this Permit: $ 2) !b 3 _ GCS Square/Linear Footage of Work:
Type of Work: ❑ Addition I ❑ Alter tioni ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: LaC 4 1 r D' � o�a-4
Specify color of color thru tile:
Submittal Fee $EL • Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $ �'py
TOTAL FEE NOW DUE $ 69 l 0
(Revised02/24/2014)
R
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
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 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. ------,
v '
OWNER or AGENT
The foregoing instrument was acknowledged before me this
.20 A day of NO u'Q m h-v 2019 by
b,, dy, /.�- 111G uc/1 who is personally known *to
me or who has produced
CONTRACTOR
The foregoing Instrument was acknowledged before me this
day
'of 20 �� by
v who Is personally known to
as me or who has produced
identification and who did take an oath. identification and who did take an oath.
as
NOTARY PUBLIC: NOTARY PUBLIC:
t
Sign: Sign
Print: Print e 114 0114 - / O
Seal: _*? ,;__ Commission # FF 917472 Seal:
„. Expires SgAember21, 2019 KAREUADWZROMERO
Two T.y F* a.0 ioo �sr�u =f •s MY COMMI IM IGIG 26 0
;i.
APPROVED BY %,� /'a j,P Plans Examiner Zoning
(Revised02/24/2014)
Structural Review Clerk