REV-19-693Miami 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) 762-494
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
R!,-CrIVED
API? 01 ggl
�q7
FBC
Master Permit No. 9, G 0,3—
Sub Permit No.�1_�
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: re-5- o q Mul 2 Iy 4 ye —
City: �(�
Miami Shores County: Miami Dade Zip: 33 !J —
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): !" 0 2 �14 <% Q G� Phone O V c—z zz3 z
Address: / O !ro Lf" I'✓"/_ 2 tvo - 4Vt
City: %/) State: Zip: �S
Tenant/Lessee Name: Phone#:
Email:
�n
� T Me9
CONTRACTOR: Company Name: M 0�_o ^U �j d 7f0j0e4 Phone#16N T
f Z- ��
Address:
City: & Lj ( ,/^ State: r C� Zip: /�0
Qualifier Name: 06j11_UIv 'et/ d &( 49,e� Phone#'X)
State Certification or Registration #: (i G 1.3 0 6-5 31, G Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:
City:
State
Zip:
Value of Work for this Permit: $ / 2+� l Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: irL� Cj v S-/�' c7 -
s wS 7`�4 L C • /✓i% uw c 020 cci sZ o 0 I � c � �{ iT' �ii c 1r-h c w7
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 100 Cl� CCF $ � • � CO/CC $
Scanning Fee $ Radon Fee $ 2 05 DBPR $ Notaiy $
Technology Fee $ Training/Education Fee $ 0 . �0 -Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ f;�=( 0
(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
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 comment must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. sen such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature I(
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
8 ``9F day of P" A 0-0 ,20 / 9 by
1!`�� Nr-J�nlhb is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
I
Sign:
Print:
as
The foregoing instrument was acknowledged beforemethis
pig day/►oaf, �," 4/ -C� 20 / I by
(�(j �fE�l! ot-( l�wwho is personally known to
me or who has produced as
identification and who did to a an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: Seal: '�'°�'"�'
"'�� Notary Public State of Florida
i L•1 Jorge Rousseau
0 �"� y` Notary Public State of Florida My Commission GG 193011
¢ Jorge Rousseau
Expires 05/04/2022
Lires05/04/2022
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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State of FlOrida
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STATE AN,) r-ILIL-S AND REOULATIONS
RECEIVED
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