PL-01-19-75 CanceledMiami Shores Village 11- =' VED
IAN 1 019
Building Department
/1 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:
A� Tel: (305) 795-2204 Fax: (305) 756-8972
�X INSPECTION LINE PHONE NUMBER: (305) 762-4949
CANCELLED FBC 2tt 0
BUILDING Master Permit No. PL
PERMIT APPLICATION �"�'' Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
'(PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
12 (�I, III /� CONTRACTOR DRAWINGS
JOB ADDRESS: I J e q 'V L I Qq 'Ef-
Citv: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type:
Flood Zone: BFE: ji/� FFE:
OWNER: Name (Fee Simple Titleholder)J:,, 11 Phone#: 7-0 `F'
Address: 0 / �''
City: State: Zip:
Tenant/Lessee Name:
Phone#:
Email: / c / - �/ Cam/ -17 ? G�
CONTRACTOR: Company Name: A i�, I6�'�CI[� ��0M�(h�1 �APhone#:
Address: 7 b�� 5' �J J,? AVt
City: C'1 i fi Mi State: Ft- Zip: '73l33
Qualifier Name: TAV IO ?0/2,-�'Phone#:
State Certification or Registration #: z- Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ h000 Square/Linear Footage of Work:
t
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: i CA/711 YL oA) �'J�"��� c1 IS - oJl qe�tX, G/e- w111 Je
Specify color of color thru tile:
i
Submittal Fee $) J Permit Fee $ 1 O� CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $.
Double Fee $
Bond $
TOTAL FEE NOW DUE $ �c� lam►
(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 reinsoection fee will be charged.
�~ Signature �—ASignature
OWNER or AGENT CONTRACTOR
The foregoing instrum was acknowledged before me this The foregoing instrumeI�JW
was acknowledged before me this
I }IIh daylinuay�A
rrof 20l by ) I f h day of A, V4 20 , by
�e01t►^+('Q _Td YCI Cn who is qsonally known to fie I Ot who is personally known to
me or who h oduced r1V�lK1 l Q�'1S i as me or who has roduced �t�/sQ v �Qw Aas
identification and ho di take a oath. identificatio and ho di ake an oa
NOT RY PUB IC: TARY PU LIC:
Sign: Sign: v
Print: ►At Print: kA ()W A,
Seal: Seal: _
ADY PRIETO
;�Y:'?�'•., YANADYPRIETO
MY COMMISSION N FF 214031 & MY COMMISSION FF 214031
ibc EXPIRES: March 25, 2019 =*'
EXPIRES: March 25, 2019
****** ov F , BondedThru to Pu I' nd nvrikt6 ****************************** +,•
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014) g/J (J V 116 c �7