REV-19-1384RECEIVED
BUILDING
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
JU 17 019
BX:
FBC 20 14
CaNCEMaster Permit No. �L- �2 -� G - !
LLED _
Sub Permit No.�o(o' I ��
BUILDING FV1 ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
a� G CONTRACTOR DRAWINGS
JOB ADDRESS: IU " \�S. —
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: — '2j j 0 k — O 3 0 0 Ols the Building Historically Designated: Yes ' NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
A I Z mrv,o6 e r
OWNER: Name (Fee Simple Titleholder):
ne#: -720--2�j%—S33,g
Address: 116 O 'd' /V W L l
O Lk a-1-
A
City: / �/\ c�yy, . State:'
c�(
CC
a� Zip: �� J 0
Tenant/Lessee Name:
Phone#:
Email: 6D M B A _ r 7 M
CONTRACTOR: Company Name:e�� 0
P_
L _ Phone#:
Address: _ r_ o C a � o
v o 4 yj
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,F
AAI
City: CJ.M-,, State:
/\i'�`\
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G
A Zip: -I
Qualifier Name: M 11 f- P rf u..
�'Q
Phone#:
State Certification or Registration #: P L
CCertificate
of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: State: Zip:
Value of Work for this Permit: $ 0
Square/Linear of Work:
Type of Work. <. ❑ Addition ❑:SAlteration
❑New
Footage
L/J`Repair/Replace'30 �;Q Demolition'
Description of Work:: ,O ' C O r r P c
f Q
f V i t P 11� (��Q` +'fl.�:..4-ti 1
-x1
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
CCF $ CO/CC $
Scanning Fee $ Radon Fee $
DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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,,rvyTr6e—
,p6sted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the ce o uch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
L51
Signature Signature
AOWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
J day of / U 120 by
%U + ck G ar C.t rk, , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY
CARLOS E CERRATO
MY COMMISSION # FF907262
Print:
The foregoing instrument was acknowledged before me this
` - day of lC.2 20 IF by
0 t- v,,- (- --- �- � /—
as me or who has produced
who is personally known to
as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: q� Seal:
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PubAe Undrimi tm
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APPROVED ✓ u� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)