DEMO-06-21-1600 CanceledMiami Shores Village RECEIVED
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:�
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
CANCELLED FBC 202a
BUILDING Master Permit NoT'(-'-MC)-1(too
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION EIRENEWAL
F_JPILUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: iQ O U N (- in &y-e-
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Construction Type: CRC Flood Zone: a BFE: FFE:
OWNER: Name (Fee Simple Titleholder): _Z� V\N MA - Z L1--(_ Phone#:
Address: G 2 On N F & of 4 g q' V Z4 S
City: Y'\z
Tenant/Lessee Name: A-+ (3y o_
State: C- L_ Zip: 3 3 t 3-d
Email: 0_-1 \zowe_-S /¢J 11-k6I\;: COVA
OZ
CONTRACTOR: Company Name: t-`� L C C.yO N STt21.lC�l O i�l- Phone#: S % (- -1 Z
Address: 5177? S -IW ' I .5t0
1ff
City: State: T L Zip: 3 3 15
n
Qualifier Name: V�CY2V�t`
State Certification or Registration #: i RC I :�L 9Y C Q Certificate of Competency #:
DESIGNER: Architect/Engineer: \')kJ� -� �wl 0 ` Phone#: 1Pi(031�b4, 102
Address: City: State: Zip: L
Value of Work for this Permit: $�i 0 0 00 0 0 Square/Linear Footage of Work: 1�O O 50 7
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee
Scanning Fee $
Permit Fee $ CCF $_
Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CO/CC $
Notary I
Double Fee $.
Bond $
TOTAL FEE NOW DUE $ _
(Revised92/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City 51
Mortgage Lenders Name (if applicable)
Mortgage Lenders Address
City
State
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 �--
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 Z 1 " by 1 day of � U. M Q ,20 a by
k�,W t.P Cc i
np�YP�.. � �Scw 5_, who is personally known to F'rtL W4 to C�Q_ I (1VvtUuyno is personally known to
me or who has produced F � L as me or who has produced 1 L as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: A NOTARY PUBLIC:
Sign: v `��"(' Sign:
Print: �l l hlerwt I IrXt �tS Print: (ID
r311VC,
MUMMY ruuu p-
Seal: gState of Florida Seal: ar StatNote
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=Comm# HR076965 0 State #Florida/ tl7 Expires 1/4/2025 �I Z - ;S o EAmm# H4/2025 5
Expires 1/4/2025
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APPROVED BY
Plans Examiner
(Revised02/24/2014)
Structural Review
Clerk