RC-02-21-485 CanceledMiami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
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INSPECTION LINE PHONE NUMBER: (305) 762-4949 $
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BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
®BUILDING ® ELECTRIC E3 ROOFING ® REVISION ® EXTENSION ®RENEWAL
PLUMBING ®MECHANICAL ® CHANGE OF CANCELLATION ® SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 'i 7 N 1
V,l I O U 5 "I -( Q C''
Dade
n c-,
Folio/Parcel#: l 10 i 1 '�- C) 3 b v Is the Building Historically Designated: Yes NO =�
Occupancy Type: _� oad: Construction Type: Flood Zone: �� BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 1 t n( �,� k one#: --_7 b e C44 !
Address: s� ::Z A) u,)
City: �oJ\ �v ��t`� r State: L Zip:
Tenant/Lessee Name: QLJ'`I) r C VI_J iQl CA Phone#: LJCXI 9 1 011
Email: C -- p v 'C�,'- 1ti\� (`D
CONTRACTOR: Company Name: _
Address:
Email:
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer: _
Phone#:
ne#:
Certificate of Competency #:
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ® Addition ® Alteration New FEI Repair/Replace 0 Demolition
A , N 1 / C
Description of Work:
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
(Revised04/05/2022)
Permit Fee $
DCA Fee $
Training/Education Fee $
CCF $
DBPR $
CO/CC $
Notary $
Double Fee $
P&Z Review $ Bond $
TOTAL FEE NOW DUE $
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 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 pd a r nspection fee will be charged.
Signature Signature
OWNER or AGENT
Thet foregoing instrument was acknowledged before (me this
1 �T day of (I, 20 ,-)4 , by
n l,� : , r,� ,0 e67 � w , is m
�. �(.Q �� y1cP. � ,who is pe sonally known to
me or hvp 6ha Fr RJ uce - 1 I. �(j,�QLS C_ as
identification _and who did take an oath.
NOTARY PUBLIC:
Sign:
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of , 20 , by
who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: Print:
1 GB!
Seal: ia�,• r; Notary Public State of Florida
Commission N HH 452227 Seal:
of titi�4' My Comm. Expires Oct 8, 2027
Bonded through National Notary Assn.
a4
APPROVED BY
Plans Examiner
Zoning
(Revised04/05/2022)
Structural Review
Clerk
lby
CAS G` V\
e, 15- b C)
� C N T �
MAR 14 2024 HI