WS-18-3403Miami 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
BUILDING C�IVCELLED
PERMIT APPLICATION _-
Master Permit No
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION
V 0 8 2018
FBC 20 1
- 03
Sub Permit No,
❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS [—]CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ' 1 ca 9 9 */ C% a A
City: Miami Shores Count : Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): A � (— r m Ix0� 1 S�pC'eS L� Phone#:
Address: C1(09 t Ket ;z lave
City: luliamiS6 State: 1—1 Zip: 3a-:L��
Tenant/Lessee Name: Phone#:
�`�
Email:
CONTRACTOR: Company Name: C3�� i (b✓i�- W r -nJ!k gyp, !Sr- Phone#3-aS 1 '4 4-_} I o4
4
Address: i� SJ '_7 t F i ql� 7
City: CJ� 0—r�. A \\ State: Zip:
Qualifier Name: 1`�MM A_ 1a c) Phone#z'z -'z�1 cs— I d
State Certification or Registration #: \\G SP %N 1 Certificate of Competency #:
DESIGNER:Architect/Engineer.'j�tVCN\J'}4'I j6.t jt"SAJ O) Phone#:
Address: a / y '5L j % i �A �`� City: t 1`State'.F- Zip:
Value of Work for this Permit: $ 3 l 4 Q Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New [Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ 150 ' G1 J Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
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 taws 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.
Signature Signature
f0 NER or AGENT CONTRACTOR
The foregoing instrument was afnl
day of 50V 20 1Q
ow' ledged before me this The foregoing instrument was acknowledged before me this
v �I' J by �_ day of C am` �` " 20 1 dby
L& me, NWke who is rson y know to who is peIly known to
me or who has produced as me or who has produced rson as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: CLAYTON PENGEL
:.r MY COMMISSION #GG245399
EXPIRES: AUG 05, 2022
»************* **•*�91iQ�►�!�?Ili1�,I��Si�4Il�UiiVIF1
APPROVED BY
(Revised02/24/2014)
NOTARY PUBLIC:
`e1MY�V'r�� MAHER SHAGRA
FF sState of Florida -Notary Public
Sign:
= *= ommis 54505
Print: q
��2t , Commission Expires
22
Seal:
Plans Examiner
Structural Review
Zoning
Clerk