RC-18-1433BUILDING
PERMIT APPLICATION
BUILDING ELECTRIC
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
REcRIV. D
Y 2 Z018
FBC 2014
CANCEmF
Master Permit No. Q�( 0 v 1
Sub Permit No.
ROOFING REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION 0 SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
I A5 N
VQ
6 ;
City:
Miami Shores
County: Miami Dade
Zip: 'Y3� 5 O
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction TType:`' Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Vi��(� ll. VCt, `��CI n Phone#: 30S �012 a5_15N
Address: kQ,5 r\)\,o ���� SA ,
City: M NUVVn� SVVo (f—S State: Zip: 33
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company N me:
Address:
City: r /�d1//
Qualifier Name: Fe1 no a,
State Certification or Registration #:
Phone#:
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: t4 4a City: State: Zip:
*Value of Work for this Permit: $ Square/Linear Footage of Work: / (7`✓' J
i
Specify color of color thru tile:
Submittal Fee $ r CT"3 Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $,
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $ C)
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
s
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. 1 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 propertkO 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 sev (7) days after the building permit is issued. In the absence of such posted notice, the
inspection wilt, not be approved and a inspection fee will be charged.
t
Signatu
The
t"'1XC&N6 or AGENT
ng instc�te was cknowledged before me this The for going instrument was acknowledged before me this
g-Vday o 20J by day of 20_, by
W V %r ho is personally known to who is personally known to
me or who has produced Gr—t%X-Q-,'� �(Q` me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
01 PNV PLel i GRISEL CARBAJAL
Seal: J « o- Notary Public -State of Florida
•
Nam. 4- rc Commission # FF 195256
OF' d,V, My Comm. Expires Feb 3, 2019
Bonded throu h Nation
a o
APPROVED BY
identification and who did take an oath.
NOTARY
Print: /iif% S
Seal: GRISEL CARBAJAL
t"aY .
o=; Notary Public -State of Florida
' • ; : • c Commission # FF 195256
My Comm. Expires Feb 3, 2019
Plans Examiner
Structural Review
r %
#############
Zoning
Clerk
(Revised02/24/2014)