ACT-12-19-2869Miami 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 ❑ ELECTRIC ❑ ROOFING
❑""PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
U 0 3 2019
BY:
FBC 2017- Cats►
Master Permit No. A64 - 1 2-19- 286a9
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: u340 th 2
Citv: Miami Shores County: Miami Dade Zip: �� 6
Folio/Parcel#: I I. 213(r — OC6 - OCYSOIs the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: `7= Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple
City: ":S�o rRS State: f—/ 4?mcI C) C— Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:
��(/425� 20Company Name: :E n c� 12L 1 2Z_ � Phone#:
'b
Address: ass
City: _�± I
Qualifier Name:
o1
RSy��s`�-9sc�i
State Certification or Registration #: \ 3 '1�55 e0d 50 O Certificate of Competency M 13 6 c—, � OSmn
DESIGNER: Architect/Engineer: « 11' wrCnn I IQ ✓%n LLB Phone#: s
Address: ��d �9 4 sl /Jhi uc b City: �1 state:/! zip: "� _ Ir_
Value of Work for this Permit: $ s�i z� Square/Linear Footage of Work:
Type of Work: ❑ Addition
Description of Work: ��
❑ Alteration P1 New ❑ Repair/Replace ❑ Demolition
Specify color of color thru tile:
Submittal Fee $ E` ' 00 Permit Fee $ -511 • CO CCF $ 1. Zia CO/CC $
Scanning Fee $ 0(• bC�' Radon Fee $ Z -00 DBPR $ Z •w Notary
Technology Fee$ c� •C-0 Training/EducationFee$ •&a
Structural Reviews$ Pz Z —ID-CV
Double Fee $ Zd0 '400
Bond $
TOTAL FEE NOW DUE $9'
(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
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
2A`1 day off-ORG-AgM .20 !! of . by
IAA whoispersonallv known to
me or who has produced as
identification and who did take an oath.
NOTARY
Sign
Print:
JEFFBYJ.YA0
Cam bft # GG 249916
EVWNovember12.2022
BoWWUN Troy Fan Ineaenne e004AW?019
APPROVED BY
Signature
R
The foregoing instrument was acknowledged before me this
�-9 day of i)o QAb� 20 (4�k , by
9n �QN who is personally known to
me or who has produced I D as
identification and who did take an oath.
Nr1TARV RI im If•
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk
Miami Shores Village
RECEIPT
(Name)
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
,Contractor
❑ Owner
❑ Architect
Picked up 2 sets of plans and (other) O �srd 2 a
Address: t (') nc) ' A 9
From the building department on this date in order to have corrections done to plans
And/or get County stamps. I understand that the plans need to be brought back to Miami
Shores Village Building Department to con g process.
Signature:
C
PERMIT CLERK INITIAL: —
RESUBMITTED DATE:
PERMIT CLERK INITIAL: