PLC-18-3672Miami Shores Village REC . I
Building Department C 12 20t8
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 I"
FB 20 P
BUILDING
CA��
Master Permit No� �kS - 3G�
r
PERMIT APPLICATION
i�
Sub Permit No.
BUILDING
ELECTRIC
❑ ROOFING
REVISION ❑ EXTENSION RENEWAL
PLUMBING
❑ MECHANICAL
❑PUBLIC WORKS
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
1501!�
0 r(P-iA-
LAI-' 1-0
City: Miami Shores
County:
Miami Dade Zip: Iss)vb
Folio/Parcel#: � j
- ZVAv
- 0,51 O
Is the Building Historically Designated: Yes NO
Occupancy Type:
Load:
Construction Type:
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
&LAA l_c4tl A1P�1Ma✓\
Phone#:
Address: )jC= /0�
City: W .\ CV\tN-QS�
State: L
Zip:
Tenant/Lessee Name: \Aj G'-
Phone#:
Email: b�ajp� 'MAv\17
��('
Yv��, . Ct>v-.-\
�
J
CONTRACTOR: Company Name:
Fv//
1-eI'Ul CQ /J/ vna h 141 c�
Phone#: T"sy .3 a 7 ks 'K a
Address: y 69 9 0" Q h 9 e
D r i v-c.
City: DgVL-e
State: f /
Zip: 333 t �l
Qualifier Name:
Phone#: 9SSY 8 6 S 9 G
State Certification or Registration #: C FC / y 99 `I Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State:
Value of Work for this Permit: $ Z, s63 •00 Square/Linear Footage of Work:
Type of Work: ❑ Addition
Description of Work: _
SInA- 6W V,
❑ Alteration ❑ New
10 121„11 AIAA /__ e-
Specify color of color thru tile:
Submittal Fee $ L--0 ` GO Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
Training/Education Fee $
❑ Repair/Replace
CCF $_
DBPR $
Zip:
❑ Demolition
CO/CC $
Notary.$_
Double Fee $
Bond $
(Rev1sed02/24/2014)
TOTAL FEE NOW DUE $
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 on 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 relnspectlon fee will be charged.
Signature Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of 20 by
Ade who is personally known 'to
me or who has produced �`�� r �— �� ✓�'S �'�3�5 as
identification and who did take an oath.
NOTARY PUBLIC:
CONTRACTOR
The foregoing instrument was acknowledged before me this
_ day of
hF C 20 . IS , by
R/ icewho is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign:
4:PrintS Print:
!/TMitw�.W�YYOr��
Seal: �''et�w, LINDA M. SMITH Seal:
.� Commission # FF 917472
44 Expires September 21, 2019
'. .... So" 7 nu Tm/ Pal V"aft 144115-7M1
APPROVED BY j �� �� Plans Examiner
Structural Review
KARELIADIAZROMERO
MY COMMISSION 8 GO 2Q2659
EXPIRES: SepWmber 2a, 2022
as
*********
Zoning
Clerk
(Revised02/24/2014)