RC-18-71BUILDING
PERMIT APPLICATION
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
RECEIVED
JAN 10 2018
94�_,
(o41
FBC 20l`4
Master Permit No.
BUILDING ❑ELECTRIC CIA V LL tWREVISION
Sub Permit No.
PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS CHANGE OF
CONTRACTOR
JOB ADDRESS: 2 S'7 WC. . 011 S' S)��
❑ EXTENSION ORENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade Zia:-3_ /(3 6
Folio/Parcel#:1I 3'Lv� -- o i ;g Sa Is the Building Historically Designated: Yes X _ NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: �77 "` FFE:
f'7/6 -022
OWNER: Name (Fee Simple Titleholder): (-h�.��►�v� Phone#:
Address:
City: IM / 4-"<< S G'3u-" State: ft 5
Tenant/Lessee Name: Phone#:
Email: J�j y�(� p �y y� /� '/
CONTRACTOR: Company Name: - 1 o 1 1 I c �J� 1 X Phone#:
Address:
City: State:
Qualifier Name:
hone#:
p331 3 5
Zip:
State Certification or Registration #:
Certificate of Competency #:
DESIGNER rchiteci/ ngineer: _ I/�'
I I�Yii�. � t`,t
Phi Phone#:
3111 ?$y' Z31 �
Address: /ye Q Z ji7w` T
City: U"% 5 Stater.. Zip: 3 3�
Value of Work for this Permit: $ )
�`�t�
Square/Linear Footage of Work:
I'
Type of Work: ❑ Addition ❑
Alteration
❑ New ❑ Repair/Replace
❑ Demolition
Description of Work:t-
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ L� O CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 7 S
(Revised02/24/2014)
Bonding Company's Name (if applicable)
I n
Bonding Company's Address
City z State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City I 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 on 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 fo 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
OWNER or GENT
The re§Wng instrument was acknowledged before me this
day of 20 1 by
4Aern'( 44 t
who is persona yei klnoowwn�t�o
me or who has produced �(_ n C.r
identification and who did take an oath.
NOTARY PUBLIC:
Signatu
CONTRACTOR
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
**r********rr*ssss*s**** sss:*ss*********s*******************ss**sss**ts**s**s*****s******rs**ss*r+t*s***
7
APPROVED BY v7 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)