WS-09-11-1674 CanceledBUILDING (4p14C" 6ywS-Z—(5-4y3
PERMIT APPLICATION
FBC 20 vv '.Xn "
Per tt Type: BUILDING ROOFING
OWNER. ame (Fee Simple Titleholder):
M
City: 1A 4 , ,4& j!-5�46g-aA State:
Tenant/Lessee Name:
Email:
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
1 VS , r9b:l(305) 762.4949 I� Ic
Permit No., �ty �) I
Master Permit
'0 /ZI a-yo
JOB ADDRESS: d D S � jV g L AV, S 7—
City: Miami Shores Cotlnty:'' %"- "Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
CON
Addn
City:
Quali
Zone:
1Ull
7/,4�
lib
3 3y/5"
State Certification or Registration #: G V r -00 5 9Q ! Certifie'1lfe of= cy #: /5�1
Contact Phone#: Fd :5 kIZ 2 i 1 Ir Email Address: /
DESIGNER: Architect/Engineer: :2;zj g *-P Pf- / ��3t ALf�10_Phone#: �3 d
Value of Work for this Permit: $ O �• Square/Linear Footage of Work:
Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: -AN--AAl MaW122" I N
*x*x**x*xxx*xxxxxxxxxxxx*x*xxx*******x*Fees*x*xx*xxx***x**********xxxxxxxxxxxxxxxx*x***
�• d
Submittal Fee $ Permit Fee $ V l Q CCF $ CO/CC $
Scanning Fee $
Radon Fee $
DBPR $ Bond
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $ �� "E' %D' — ;I1'2U k�
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 CON NCEMENT:'
Notice to Applicant: As a condition to the issuance of a building perAll!(�Woofled value exceeding $2500, the applicant must
promise in good faith drat a copy of the notice of commencement and cons law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recordecommencement must be posted at the job site
for the first inspection which occurs seven ( after the building permit is issued. In the Bence of such �p ce, the
inspection will not be appro and a reins etion f will be charged. A _ / /i
day of
who is
or who has produced
As identification and who did take W1?oath. as
NOTA Y PUBLIC: g p'N NOT
C� �ti1'p1ti
Sign: ` Sign:
Print: Print:
My Commission Expires: My C
nto me or who has produced
identification and who did take an oath.
APPROVED BY� ` �o` Z� Plans Examiner Zoning
SIli
t ctural Review
:4 }�� •:.
(Revised 07/10/07)(Revised ON 10/2009)(Revised 3/15/09)