EL-09-19-2285 CanceledBUILDING
Miami Shores Village RCCC1,11CQ
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 �) J
Tel: (305) 795-2204 Fax: (305) 756-8972
ACCIN CLIEN �l``'1./l (305)762-4949
G FBC 201`fi �
(C.PI*Le.4d by DQO-05-213 -1255 RG- ra'iq- a l
PERMIT APPLICATION
❑BUILDING QELECTRIC ❑ ROOFING
Master Permit No.
Sub Permit No.
REVISION ❑ EXTENSION []RENEWAL
F-IPLUMBING MECHANICAL ❑PUBLIC WORKS 0 CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: V O N F• • \ O 1 (_ "T
City Miami Shores County: Miami Dade Zip:
Folio/Parcel#: , QJ 3 1' O 13 " d(3gO Is the Building Historically Designated: Yes NO
Occupancy Type:&Y Load: Construction Type: C_ Flood Zone: BFE: FFE:
`9 G-2-17- �30�
OWNER:Name(FeeSimple Titleholder):MRAitJPkPpEZUMA 'V_ANXS'•T%LF Phone#: 3o5•r1S'1-17�L1{
Address:, Q tom\ li-_ � 7 S
City: M��'l�T.a i f3woys, State: Zip: r3`3 � (o I
Tenant/Lessee Name: Phone#:�04'
Email: n V\ C Q )5. CS Q cd, C A"
CONTRACTOR: Company Name:: '�p C o P1 1 S Phone#: 2Ml
Address: �? lyyI LeP 1 D' '05�_/a 4z /D 1
city: _s-�v
Qualifier Name:
State Certification or Registration #: / _61e,) 1 % (— Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address: City:
Value of Work for this Permit: $ �b 600 Square/Linear Footage of Work:
Zip: 3 3 ,/ fG
, ? l 1 —Ci. ? ? =fLZ-)
Zip:
Type of Work: ❑ Addition ❑ Alteration ❑ New FLI epai Replace ❑ Demolition
Description of Work: IF CkA I A'�% ( ir�o;2
Specify color of color thru i
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Permit Fee $
Radon Fee $
Training/Education Fee $
COP $ CO/CC $
DBPR $ Notary
Double Fee $
Bond $
(Revised02/24/2014)
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 and a reinspection fee will be charged.
Signature Signature
NERorAGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
4 day of s'E�7EM i��2. 20 C! , by o(G day of 20 , by
N Ji MMtNP eU who is personally known to . A 4r r' Ci. i l , who is_perso a y known
me or who has produced D2�t LFJ9" �A-'_C_ N S� as
identification and who did take an oath.
NOTARY PUBLIC:
me or who has produced
identification and who did take an oath.
NOTARY PU,BLI
RQtwv public • Statd of Fbnda
Sign: co onMelon • FF 979238
es da
w - Print: r.N. I ndedlMoo�Maoonal Notary Assn.
SINDIA ALVAREZ Seal:
MY COMMISSION N GG 238273
EXPIRES: September 3,2022
Bonded Thru Notary Public URdenniten
as
APPROVED Bff OiV7/% Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)
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