CC-10-19-2358 Canceledp�IZ�iZ�y°, 1 Miami Shores Village K`; _ .,E;
Building Department OCT 0720t9
30050 N.E.2nd Avenue, Miami Shores, Florida 33138
Vu i S Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 C5�-11
CANCELLED FBC eon
BUILDING Master Permit No.
PERMIT APPLICATION sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS:
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: ,Miami Shores Cuty: Miami Dade Zip: 33 �c3 8
Folio/Parcel#: I L � --�o10 O I -7 is the Building Historically Designated: Yes NO
M2.r C-- Le >r e l
Occupancy Type: Load: Construction ype: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titlehold4
Address: 134� }3 f t
City: ry�\
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address:
City:
Qualifier Name:
State Certification or Registration M
DESIGNER: Architect/Engineer:
Address: 1� (916 S1--)
Value of Work for this Permit: $
Type of Work: ❑ Addition
Description of Work: E
C, 6 j 02t-'P , (2 r(
V=� ZIP: 3 313 1
ofCompetency#: Zb
Phone#:
I
-)CCC=-4 City:
)J , o C) Ci Square/Linear Footage of
Alteration ❑ New ❑ Repair/F
Specify color of color thru tile:
4�12,0 •00
S bmittal Fee $ ' •w Permit Fee $
Scanning Fee $— Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews
itate: Zip:
p
0 7� a % utIN. -ag la
❑ Demolition
CCF $ CO/CC $
DBPR$ Notary:
Double Fee $.
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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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 d 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
l C O Q �) day of ver . 20 19 by
German Rl"JC\C1U who is personally known to
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of . 20 . by
me e,or who has produced as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: r-�f?SQ • �1 CCI ( )
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
as
Seal: ROSA ISABEL RICARDO Seal:
> As Notary Public -State o; Florida
Commission = GG 185189
My CommFF. Expire^^sFIeb ff13,2pp0t2tgq2
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APPROVED BY
Plans Examiner
Zoning
IRevised02/24/20141
Structural Review
Clerk
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