RC-18-2477 (2)aMiami Shores Village
BUILDING
PERMIT APPLICATION
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
LLED
FB�' C M 1
Master Permit No. RL I � - Z4� i
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLAT
CONTRACTOR 7
JOB ADDRESS:
0
❑ RENEWAL
N [:]SHOP
DRAWINGS
Folio/Parcel#: Is the Building Histori ly Designated: Yes
Occupancy Type: Load: Construction Type: Floo one: BFE:
OWNER: Name (Fee Simple Titleholder):
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Address: 2Z3� l 9M-J W.c hc\ -\-0 0
p
City: 1A`O �kS:4 lSU oQzk State:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address:
city: j_ \\S4 k o ao" 1,
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
3� I-�Q
NO
FFE:
hone#: - Z Z 2 •fin (o'el
one#:
p: �31 �
-1y • Z2-2 - (OW I
Zip: 3� 1 3
Phone#:
Certificate of Competency #:
hone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work: 4;P�0- --j-z der
Type of Work: ❑ Addition ❑ teration ❑ New [Repair/Replace ❑ Demolition
Description of Work: 2-Q P� id► a MIE —
Specify color of color thru tile:
R
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $_
Structural Reviews
Training/Education Fee $
Double Fee $ _
Bond $
TOTAL FEE NOW DUE $ _
(Revised02/24/2014)
Bonding Company's Name (if applicable)
1
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 ccurs seven ,ays after the building permit is issued. In the absence of such posted notice, the
inspection will nota�approved and a reins I'7 n fee will be charged.
ER or/AGENT
Thelfo egoing i stFument was acknowledged before me this
day of 20 by
ho is personally known to
me or who has produced ram, t�2►N/rult-- as
identification and who did take an oath.
NOTARY PUBLIC:
r r .- Nam. .•�
Sign: �
Print:
=0 ;a 01 d 0-
Seal: zp ; �•
'°p,b/dX 9
APPROVED BY
Signature
C81iP►�1310110F.
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 , by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
**********************************************************
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk