RC-18-629`v`kib V jr. r1
�rx�NMiami Shores Village
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BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
UILDING ❑ ELECTRIC ROOFING REVISION EXTENSION [:]RENEWAL❑PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
�.� �:J
A� 12 201a
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20��
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❑ ❑❑
JOB ADDRESS: _ 101 tir" IQ% o�DO
City: Miami Shores County: Miami Dade Zip: 221/11
Folio/Parcel#: A- ZI1i - �) - 0160 —is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): dam 1t A Phone#: 305-
Address: 0, � k t�lJ gk
City: �� '�� *) State: Zip: 33161
Tenant/Lessee Name:
Email:
n e#:
l�
CONTRACTOR: Company Name: C l UIV�C N IP Phone#:
Address:
City: State:
Qualifier Name:
State Certification or Registration #:
one#:
Certificate of Competency #:
DESIGNER: Architect/Engineer: :A si uy .s . eipxki '`�cwL ec Phone#: 96�g ^ 9135
Address: WIS �a, Q, Cow o 4�9�_City: C 5tate ��`1)/1 1 P_ fL, Zip:
Value of Work for this Permit: $ � �d , �Square/Linear Footage of Work:
Type of Work: Addition a Alteration El New ❑ Repair/Replace ❑ Demolition
Description of Work: 9�8a- 'F ST o '%6'DAJ j� 6 (',,A" G to 6S
K �r1�e�> > NiM C4M k t y 2UF �� FE + n tin 4r�1
Specify color of color thru tile:
Submittal Fee $ ZCp ' � Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/CC $ 190
DBPR $ Notary $
Double Fee $
Bond $ ,LO a:!)
(Revised02/24/2014)
TOTAL FEE NOW DUE $
'Kv-I;A �-* ? -)A 0 rl i
Bonding Company's Name (if applicable)
Bonding Company's Add
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 such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before
me this The foregoing instrument was acknowledged before me this
_12- day of 20 by day of 20 by
ANN� —�w`ho personally known to who is personally known to
me or who has producedL,� me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY P B IC:
NOTARY PUBLIC:
Sign:
Sign:
Print:
�U
Print:
Seal:
Y
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Seal:
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Notary ?ublic state of Florida
Sindia Alvarez
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My Commission FF 156750
oQ Expires 0910312018-
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APPROVED BY
Plans Examiner `� Zoning
Structural Review Clerk
d
(Revised02/24/2014)