PLC-18-3673Miami Shores Village
Building Department
EC i 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949FBC
201�OH
BUILDING
Master Permit No.
r
l '
PERMIT APPLICATION
4h Sub Permit No.
❑ BUILDING
❑ ELECTRIC
❑ ROOFING ❑ REVISION ❑ EXTENSION
[:]RENEWAL
_IIIPLUMBING
``����
❑ MECHANICAL
[:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION
❑ SHOP
CONTRACTOR
�
DRAWINGS
JOB ADDRESS:
`
v � S��ee 4 oyi 1-r � 40
City: Miami Shores
County: Miami Dade Zip:
Folio/Parcel#: `
— 2, ?6 - O 5
3 — (%5 9�0 Is the Building Historically Designated: Yes
NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �l e �l"Tl Z Phone#:
Address: -2, Y✓� vs�
� I �
City: • i ,'1 3 State: I- Zip:.%
Tenant/Lessee Name: Phone#:
Email:4)4s'
J
CONTRACTOR: Company Name: Fun S eiyi G-p P/i^bi n!2 Phone#: 1?5-c-1 3 a -7 BSF�
Address: y619 o(g09e drive NA\ll -e , F/ -, Z3 1 `1
City: D clul L State: F I Zip: ::,)I `-j
Qualifier Name: To,y'Ntt ffndfOdt Phone#: 95' `> P?
State Certification or Registration #: (�'F -�"OI 9 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#: .
Address: 2 City: State: Zip:
Value of Work for this Permit: $ 2 I Sf j • OU Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ Newer/ ❑ Repair/Replace ❑ Demolition
Description of Work: K� PTQI �' G{M Aut aff mue C�IG� p 4-6
lyolde
414
Specify co/or pjf c61or'tfik6 tile•
f N;,haav,..
Submittal Feef$ S"' '" '� -_ hermit Fee $ ; `"CCF $ I V MI'" CO/CC $•_
Scanning Fee $" "'"" �"i"":`Railon Fee $ ` DBPR $ T Notary $
Technology Fee $
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ ���
(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.....
1
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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
'23''r day of OGITL-r- , 20 /J by
4 zx)1 a2T l 2 , who is personally known to
me or who has produced �f iQ rL �IV�S llu as
identification and who did take an oath.
NOTARY PUBLIC:
CONTRACTOR
The foregoing instrument was acknowledged before me this
_ day/ of � �L 120 t e by
JO J f N YJy'Z ,-Qd Q , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign: / �1 Sign:_
Print: `1/✓�I� N% ! / /� Print:
'w•�«�+wrnr
Seal: LINDAM.SMITH Seal:
COmmission 9 FF 917472
•a s EX*m September 21, 2019ow" Thm
APPROVED BY � I d �d //,/ Plans Examiner
Structural Review
KAREUADIAZ ROMERO
MY COMMMON / GO 20M
EXPIRES: SepleflibW 26.2022
as
Zoning
Clerk
(Revised02/24/2014)