WS-17-1535Miami Shores Village
Building Department RECEIVED
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 ��N�017
INSPECTION LINE PHONE NUMBER: (305) 762-4%9
BUILDING CANCELLED
PERMIT APPLICATION
FBC 20H
Master Permit No.
Sub Permit No. W
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION tENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION DSHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: C4 T ` ! I V L—
City: Miami Shores County: Miami Dade Zia: ��
Folio/Parcel#: / 132o 6 0o l oci zo Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construct'on Type: lood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):--u) l iU �a Phone#: 05vw
�- n
City: 6 a 1 �> (5y-e--5 State: Zip: 1
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
AddresV(I
TQ z- 5(
City: ►'V! I
Qualifier Name:
CJ
State Certification or Registration #: L= U Certificate of Competency #:
DESIGNER: Archit�te/ct/Engineer:. 1 1 5 � � Phone#: U36S)3 5' 33 3
Address: w — -1002- City: State:: Zip: -3 3 Z
Value of Work for this Permit: $ s O�y- `S' Square/Linear Footage of Work: V
Type of Work: ❑ Addjti9n Alteration [ New , ❑ Repair/Replace, ❑ Demolition,
Description of �IVork:
SEW Mgm-g W, �7�►7L:�[i�:��•r��l9�iR/ILf�i�IL'i?i�l�XLGiSi7I�lI`
Specify color of color thru the:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
(Revised02/24/2014)
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF $ CO/CC $ _
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 2-
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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.
Signature `� Signature
Owner or Agent t \_ #Cont*ractor lw
`7
The foregoing instrument was ackngwlfgged before me this _j r` The foregoing instrument was acknowledged before me this—�e, 11
day of 20 A7 by l�J 1 I I \ a M L !'I U4 ' day of00 e -, 20 L7, by LP 1ct
who is personally known to me or who has produced who is personally known to me or who has produced
s identification and who did take an oath. as identification and who did take an oath.
NOTAR NOTARY P
Sign: Sign:
Print:
1 Print:
=AY CO SSION # GG072040 =+�
My Commi My Co COMMI I # GG072040
EX S March 15, 2021
'',,,. •'•• ''•,,a„ ,� • EXPIRE8 March 15, 2021
APPROVED BY ! ` ' Plans Examiner Zoning
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)