RC-14-2071BUILDING
PERMIT APPLICATION
BUILDING &ELECTRIC
❑PLUMBING ❑ MECHANICAL
JOB ADDRESS: ;2--"')
Miami Shores Village ;7SEP
IVED
Building Department 24 2014
QJ1k.
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 �L3
rCANCELLEI�aster Permit No.
Sub Permit No.
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINr,,;
A_-1q_--' 173 sl
City: Miami Shores County: Miami Dade Zip:
4 ��f�a
Folio/Parcel#: �/Q _ ! �J Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): igCi (`e !S"Phone'#:S6� . s ����%2�
Address: 6?l A i �1r �wC,
City: //-/- -zel(1 ikz, State:
Tenant/Lessee Name:
Email:
hone#:
CONTRACTOR: Company Name: kAQQ �a �� ��%' e ��� � hone#:
Address: �� �J�J ('�
`? S �a 4 2co o 9LDf,�q
City: ��x�GLXL State:
Zip:
Qualifier Name: ® �✓��'7�q'L Z Phone#: �g to2 OC112) Co
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 3 �� �� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: 5se> 'U / p K l h A n
_Co Pam.?r-rz 7�0 S -- { 40-i
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Permit Fee $ CCF $ CO/CC $
Radon Fee $ DBPR $ Notary $
Training/Education Fee $ Double Fee $ _
Bond $
TOTAL FEE NOW DUE $
w
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 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 s p ed notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature �2tit Cv'� Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowled ed before me this
day of eM , 20, by �. J day of %` ,:7 ��ZO % , by
l�vho is personally known to ALr Rt 1y Fio ispersonallyknown to
me or who has produced
identification ar#d who did take an oath.
NOTARY PUBLI
k Sign: !V
Print: r
Seal: *M,0-
,4,* Y COMMISSION # FF 012651
EXPIRES: April 28, 2017
NBonded Thru Budget Notary Service
as me or who has produced
identification and who did take an oath.
N 07
k
Sign
Prirr
Seal
as
############################################################################################################
APPROVED BY
Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)