WS-16-2983Miami Shores Village CEIVI
g Nov 01 2016
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
y Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 E5\,}.
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FFBC 20 I`-�
BUILDING CANCELLEBasterPermitNo.�s �b-Z132PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: q
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City: Miami Shores/ /1 County: Miami Dade Zip: 33�
Folio/Parcel#: 11
� 2 0 6 0Q 1 Q V �0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: \ �Const1ruction Type: Flood Zone: BFE: FIFE:
OWNER: Name (FeeSimpleTitleholder): W 1' `l 0-Y'rk U ✓)e� Phone# �s 7 7 Z2��
Address: / T,/ _N e "/ Aye -
City: Mgm1 Shares State:
��OrJ(�L1J
Zip: 3�!
Tenant/Lessee Name:
Phone#:
Email:
CONTRACTOR: Company Name:
al/?
(✓'
O one#:
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Address: 6) 2
7
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City: 1� �1'11 1
Stater
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Zip: 3 J S
Qualifier Name:R.Q� ig_1n1�
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_ Phone#(3a5)Z-6I-505
State Certification or Registration #: GGc1 14
c�
80 /
Certificate of Competency #:
DESIGNER: Arch it`e/ct/Engineer:
rJ lJ �4 rC`
Phone# � 3f-S-5 335
Address: N
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J u
City: 14 I1L 01 i State: Zip:
Value of Work for this Permit: $
Square/Linear
Footage of Work: /5
Type of Work: ❑ Addition
❑ Alteration
❑ New
❑ Repair/Replace ❑ Demolition
Description of
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Work:
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Lfj1�j�j
7'l
yt t/H2
_S&S5
- i-� ��5 .flo�✓h :
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l.Il r/ /-P_DLQ�P
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D ',/YJ'lir? /l tJ�'1 b�Y W s- �J M 6 O /
Specify color of color thru tile:
Submittal Fee $ P5 0 Permit Fee $ CCF $ "1 CO/CC $-
/� Co O
Scanning Fee $ �) Radon Fee $ DBPR $ (o Notary $ --�
Technology Fee $ 2 Training/Education Fee $ Double Fee $-
Structural Reviews $ Bond $ --Q- _
TOTAL FEE NOW DUE $
(Revised02/24/2014)
I
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.
Cignature NJ
.�!l11111. /I'///fir.,._ /
OWNER or AGENT• r
The foregoing instrument a acknowledged before me this
day of(', 0� 20 by
i ���'am 1ri�er who is personally known to
me or who has produced
s
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
as
The foregoing instrument wa acl owledged before me this
day of ,- jt 'r 20, by
/1^ CLrn-i n %� Glib who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
MY COMMIS51bN # EH8T2146 -a MY COMMISSION # FE872148
Seal: - Seal:
?ba, EXPIRES March 15, 2017
•, EXPIRES March 15, 2017
(407) 398-0153 FloridaNdar7Smiw eom
(407) �9.0163 Florida be wrn
APPROVED BY ) Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)