WS-15-2244BUILDING
PERMIT APPLICATION
Miami Shores Village SEP 0 7015 '
Building Department BY;_
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 201
Master Permit No. V V S 15 " 2Z f
Sub Permit No.
'$j�BBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: pp
City: Miami Shores County: Miami Dade Zip: 53) LQf
Folio/Parcel#: Is the Building Historically Designated: Yes NO _Y
Occupancy Type: Load: Construction Type:
Zone: BFE: FFE:
OWNER: (Fee Simple Titleholder): �� �- �� �
nFlood
9�
--�ly .� Phone#: �L)5 3�3, DY0S
(N�ame
me
Address: 11` ;9,�') Kxu utp L<,---r
City: ffi�a,fi► Stater
Zip: 3:3 1Q
Tenant/Lessee Name:
Phone#:
Email:_�t�SO I lAC7��1&�• C(SYY�
CONTRACTOR: Company Name: M OW NyIz_7e_
Phone#:
Address:
City: State:
Zip:
Qualifier Name:
Phone#:
State Certification or Registration #:
Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: State: Zip:
Value of Work for this Permit: Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New
[Repair/Replace ❑ Demolition
Description of Work: KEG) 4--kpNT .�� C-A,,w13c
%2�_PAI R
Specify colorofcolor thru tile:
Submittal Fee $QV 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 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.
Signat:::� Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of S�-"�7 �1�'� 20 by
90V-Ar*X),, who is personally known to
me or who has produced -�L'D �A \JQF- U C,fNSC) as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: ro�oRr c�a No;ary ?ublic State of Florida
Sindia Alvarez
+� ca My Commission FF 158750
�tof�oa' Expires 09/03f2018
********** * * *
APPROVED BY lr-17W (I %/
The foregoing instrument was acknowledged before me this
day of , 20 by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
*****************************************************
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk