WS-11-18-3489 CanceledMiami Shores Village
1BuildingUDepartmlentRY
R
Tel: (305) 795-2204 Fax: (305) 756-8972 T)
t(NIC1Rt4Q$F$s(305)762-4949 FBC 20
BUILDING Y-Cpk&C-4A bi vs-12-2Z-31g�asterPermit No. -C ICJ-34+Q�
PERMI APPLICATION Sub Permit No. ULS (i, - � 4 8
7:MLDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): GZp Phone#: 7fiD:5 %f /2 Z-;jZ'<6
Address:
City: fAk f.1 �-6 t6 10 Stater Zip:
Tenant/Lessee Name: Phone#:
Email:
�s
Address:
City: z
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer: c1b5
Zip: :IZL9
4- LL,;-9 Phone#: 36S 7z6
_Certificate of Competency #:
7
5 fir% 't'14 Phone#:
Zip:
Value of Work for this Permit: $ lg�60. " Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: IhlW ✓s/ bWS 1�. a"A-S
Specify color of color thru tile:
Submittal Fee $ �>(_) �� Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/Cc $
DBPR$ Notary:
Double Fee $
Bond $
TOTALFEENOWDUE$ 63.
(Revised02/24/2014)
I
Bonding Company's Name (if applicable)
Bonding Company's Address_
City St
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
an
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.
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of NU`tsJi—tp�� "EO , 20 If S . by
�Ihc'0'issppersonally known to ,
me or who has produceddl
identification and who did take an oath.
NOTARY PUBLIC:
The foregoing instrument wasyrcknowledged before me this
day of 0 a 141 i 20 ler by
is personally known to
me erwhoitirpraddeeel a5
Wan6fieeiiotrand who did take an oath.
NOTARY PUBLIC:
AStructural Review Clerk
(Revised02/24/2014)