RC-09-19-2284 CanceledKa'1.4 I�IZ22U1�
molW IZ110 I9 Miami Shores Village
Building Department IR,ECEIivED
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ('CT 1 J iB
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
CANCELLED 23- 46 FBC 20(����''
BUILDING P Y Master Permit No.
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
Sub Permit
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: �21 :Jg2_
Occupancy Type: Load: Construction Type:
the Building Historically Designated: yes NO
Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): ,� N _J L ��, . �.�r� Phon e#:
Address: & M N ia 007 7 !7 ( t—
City: �1 , Z9p e-� State: i� �,� 1 (�( Zip:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: ( I(L �� 'IL( 2M o n.� Phone#:
Address: l2�pl �QrO �/� r� /
City: U `� l.h 0 �/ 1 State: Zip: Q5D 1p L �S
Qualifier Name: S� l� ���1 c��� 1 Phone#: OQ —61(n�
State Certification or Registration M 69�2 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Value of Work for this Permit:
Type of Work: ❑ Addition ❑ Alteration
Description of Work:
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $.
Technology Fee
Structural Reviews $
Radon Fee $
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace
Training/Education Fee $
Zip:
❑ Demolition
CCF $ CO/CC $
DBPR$ Notary.
Double Fee $
Bond $
TOTAL FEE NOW DUE $ _
`a aic
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lenders Address
City State
SM
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 on 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.
OWNER or AGENT
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:
as
who is personally known to
me or who has produced 4f�7t— — as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign:
Print: Print:
Seal: Seal:
a �mg k
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o' oz0ti�
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****************+***********************************r******r*r*********************+*****•.s/y**'tJk#w#silt
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APPROVED BY
Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)