REV-11-19-2797 Canceled` Miami Shores Village M V
I
Building Department v v2 ij
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 %
Tel: (305) 795-2204 Fax: (305) 756-8972 BY: f
INSPECTION LINE PHONE NUMBER: (305) 762-4949
CANCELLED 0�llBC o
BUILDING Master Permit No. � (q I I — i
PERMIT APPLICATION Sub Permit No. NV- II-1 1 -.7-M
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
� � �� � CONTRACTOR
JOB ADDRESS:
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County:
Miami Dade
Zip: 315 i 3Folio/Parcel#:
if Pam)
i ` 13 b 0 s, 1
� U
Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type: Flood Zone:
BFE: FFE:
Phone#:
OWNER: Name (Fee Simple Titleholder):
1
Address: 349 kj )04j �
— I "3---�-
City: W{/I G% i
State:
(
V�
Zip: �►
Tenant/Lessee Name: N/�E
I A
Phone#: T—
Email: e,t'Ioai; V ii'lik-Q- .
CONTRACTOR: Company Name:
Address:
City: State:
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Phone#:
ne#:
Certificate of Competency #: _
Phone#:
Zip:
Address: City: State: Zip:
Value of Work for this Permit: $ X Square/Linear Footage of Work:
Type of Work: ❑ Addition �❑ Alteration - ❑ New i I �� Repair/Replacq Demolition
P
Descri tion of Work: I'�►G�I �' V T� C �1 "" O-C
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ /
]EL-
(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 reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of II�V�':�v 20 i by
who i perso�ITy 1Cnowo
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
,,em,�ss.� Notary Public State of Florida
Seal: ap Seal:
NN Jose A Delgado
My Commission GG 323842
jap Expires 07/04/2023
APPROVED BY
tr�Plans Examiner
as
Zoning
(Revised02/24/2014)
Structural Review
Clerk