FW-5-18-1391 CanceledBUILDING
Miami Shores Village
Building Department
10050 3nd Avenue, Miami Shores, Florida 33138 MAY 2 2 2010
Tel:
(305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
A N /FBC 20 1�
C `" CELLED Master Permit
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: S %V E qOS''' SfQi;ET
City Miami Shores County Miami Dade zip: 3 3 13 $
Folio/Parcel#: 41- ,2 436 - 00 6- 0090 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): 1 ICrIAKO tJes5le-A PWHA,e Phone#:(g14) 930—G+3�
Address:-5 NE 406'0 5TeEt T
City: HIA-r-fl SHOPES State: FL- Zip: .931316
Tenant/Lessee Name: _
Email: JeSSFG20
Com
CONTRACTOR: Company Name: 8 821 NATIOAIAL 1301,O ERS Phone#: (q5q) 3gI 10 2 g
Address: 4501'3 SW 30 $r2ccT ple--'yL ;9//:(50s) >0026-6) ,Jct y
City: .PA-v IQ State: F L- Zip: 3333 1 /
Qualifier Name: {ANT 0 ml O 9c L.1610 Phone#: C q5q) 3 T 3 0 2q
State Certification or Registration #: GC 45 2. 2,5 W Certificate of Competency #:
DESIGNER: Architect/Engineer:
State:
Value of Work for this Permit: $ 13o O Square/Linear Footage of Work:
Zip:
I[-i6 LIK.
J +1
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: WDObEN ,DO 02. P-Of& FCAJC.6 %HGPSU1ZVME710TS : 4S INCRES WiDr+4
SIx FEET TALL
Specify color of color thru tile:
Submittal Fee
Scanning Fee $
Technology Fee
Structural Reviews $
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF $ 'c0/CC $
DBPR$ Notary:
Double Fee $
Bond $
TOTAL FEE NOW DUE $ jcj
�®
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's
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 reinSDection fee will be charoed.
Signature
OWNE4 or AGENT
The foregoing instrument was acknowledged before me this
�dayof 20 by
ho is prrersonally known to
me or who has produced U C L- r as
identification and who did take an oath.
Al-"� .06�,;�
CONTRACTOR
The foregoing instrument was acknowledged before me this
IIdayof M 20 by
1 d Qho' personally known to
me who has produced as
identification and who did take an oath.
NOTARY PUB 411-�� C: NOTARY PUB ISign:Sign: t
Print: S' 4,5+4- I ✓Yl6TO Print: S' tS11 lYY1
Seal:
APPROVED BY
Silvana Kishimoto
Commission t GG035453
Expires: October 3, 2020
Seal:
Plans Examiner
Structural Review
Silvana Kishimoto
Commission 1 GG035453
Expjres: October 3.9mn
iitt+Rik
Zoning
Clerk
(Revised02/24/2014)