EL-15-2202Miami 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
PERMIT APPLICATION
❑BUILDING 14 ELECTRIC ❑ ROOFING
CE
AUG 2315
FBC 20 Lk S
c.�
Master Permit No.,
J
Sub Permit No. 1:� �ZU
❑ REVISION ❑ EXTENSION [:]RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: ?2;7157 .
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: lr nLoad. Construction Type: &e_C'{'Y1 f Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): T/ J �" �(-� c.J�� Phone#: yZDS—'
Address: 10 ///I A/,,1
City: 'a C7"'yn shoe S State:
Tenant/Lessee Name:
Email
CONTRACTOR: Company Name:
Address: 7O0 6 t S
/v
O U j Loo l <
of ho zqy ob G(ecf
p: 33150
City: ) Cvn I v State: L Zip: v / 7 ?�
QualifierName: '7` Phone#: /7
State Certification or Registration #: E QQ ��� Certificate of Competency #:1/l= 000
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 600, U O Square/Linear Footage of Work:
Type of Work: ❑
Addition ❑
Alteration ❑ New
19 Repair/Re/place ❑ Demolition
Description of Work:
6. Pa r
Z[ e C iy( Cotf p-t
d ( e. f ✓) IZ# khe✓I rv�
Specify color of colorthru ti1Le.:�.
Submittal Fee $ t. ✓t`' "" 4 Permit Fee $ •.f d`d.ol� CCF $
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
rE
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.
� 1
Signature/, ea Sign atur
WNER or AGENT CONTR CTOR
The (foregoing instrument was acknowledged before me this
o� day of 4) L�l 20 / cS by
Fri d 4 who is personally known to
me or who has produced JSM-'5*0- 5�;-"C1 11% as
identification and who did take an oath.
NOTARY P105LIC:
The foregoing instrument was acknowledged before me this
t� 8 day of F,% 1�1 20 /3 by
�� ✓1 fZ --(—e (fo r who is personally known to
me or who has produced�L/6�o 6q 1Jq� l as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 1/l.(J"" Sign: IF V
Pri Q 6tLtd Print:/ movLct2f is
�+o MANUEL REGIS
Seal: +► MANUEL REGIS Seal: Notary Public Star► of Florida
Notary Public. Sire of IilDtm s�� My Conm. Expires Nov. 30, 2020
NY Ca=. Fires Nor. 30, � w No. D0389723
asw
************ **** ** ***A***�**** ******************** ************
►►ry on}Unftr*yftm
APPROVED BY /6 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)