MC-10-19-2445 Canceled'
Mami Shores Village— D
Building Department
V
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBc ZoMc-,o_iq_;445'
CANCELLEDaster
BUILDING
Permit No.
PERMIT APPLICATION
Sub Permit No.
❑BUILDING ❑ ELECTRIC
❑ ROOFING ❑ REVISION ❑ EXTENSION [U4ENEWAL
PLUMBING MECHANICAL
❑PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
F-' �-�(
JOB ADDRESS:0 1/ MW ioll"S1}
City: Miami S�hor+essy
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County: Miami Dade Zip: 333 \BYO
^ /�
Folio/Parcel#:(12I�'711�1J1/. lJ�� V Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type: Flood Zone: BEE: FEE:
OWNER: Name (Fee Simple Titleholder):
�'�
tp�,,e3
?,i
& z2awt u Phone#.COtL : "�—zGG J
Address: o I WW tr t�
City: Wad-n( shores
�2�2 �
State: Zip: 331w
Tenant/Lessee Name:
Phone#:
Email:
CONTRACTOR: Company Name: AFs
sue, Ie �, p,r ��2
w, t K-CI f-c Phone#:ax-a�--73-9 >
Address: > cSw Log
pY�,,
Ave_
City: M
g191214
iaroL
State: L Zip:
Qualifier Name: L-,)UV III /l'II/L� Cr.�C. Phone#:
State Certification or Registration #LMCl2!4 9 7
S 3 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ -:�' 1 5D Square/LinearrFF000tage of Work:
Type of Work: ElElLam Addition ❑ Alteration New ( Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee
Structural Reviews
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $ n
Bond $
TOTAL FEE NOW DUE$
(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.
i
I OWNER or AGENT
The foregoing instrument was acknowledged before me this
} day -oaf OC Ui7�' 20 o by
9Y� c IQi11�1 �4 , who is personally known to
me or who has produced t-- OLI as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal: e
1y%
OrM1
essiissRiist►►itReii
APPROVED BY
Signature
_ 74 -
COT R
The foregoing instrument was acknowledged before me this
EVA day o))f,�.�o,.���bcr 20 �� , by
�(11115 L�[C L�IL. who i erson�ally knnwn-Ae
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Print
State dra ![)
io Dominguez
S)T Seal:
mission 186321
03114/2/14/202222
r'W,_ Notary Public State of Flor's
4ro Cassandra M Dominguez
• MY Commission GG 186321
a pdk' Expires 03/14/2022
as
rtrtsr.sa
Zoning
(Revised02/24/2014)
Structural Review
Clerk