RF-3-16-643 Canceled�\ C
BUILDING
Miami Shores Village
jq%, Building Department
I "-„II �10050 N.E.2nd Avenue, Miami Shores, Florida 33138 M R 1 d �81e
'n•.`F/l'Tri Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 BY�
25 �0)6
� CANCELLED FBC 20
VOicefw, ( rep IA",A tat Master Permit No. RC (G `k)q3
PERMIT APPLICATION Rr" it-lo-zs��Sub Permit No
❑BUILDING ❑ ELECTRIC 0 ROOFING ❑ REVISION ❑ EXTENSION ❑RENFWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
JOB ADDRESS:
Occupancy Type: PP-5 _ Load: _
OWNER: Name (Fee Simple �Tjittllehol
Addrpcc: a R S
City: /d/1
Tenant/Lessee Name:
A rd'iF•llil
CONTRACTOR: Company Name:
Address: SOOc; C
City:
l0
❑ CANCELLATION ❑ SHOP
DRAWINGS
Is%t�h BuMing Historically Designated: Yes
Construction Type: 77;C/Flood Zone: BFE: _
NO x
FFE:
781)-y 7 Y-50) 0
F7L Zip: 3 3/ � y
-Cn 0,7 %i" cT,0 P, d Nevl a me,n Phone#: 7�L
0oa d S 4 /
State: /c L Zip: 3 3 3 1/
Qualifier Name: X ind, -Na , "P/' -eeq Phone#: 9S y S- V / S/ 7
State Certification or Registration #: CC(' // 7;&'a _r ertificate of Competency #:
DESIGNER: Architect/Engineer: Phone
Value of Work for this Permit:
Type of Work: ❑ Addition
Description of Work:
01-76- City: Stated 2Zip:
Square/Linear Footage of Work: CT" '? 7 4 J
❑ Alteration ❑ New IL Re air/Replace ❑ Demolition
- I G� / � - -- 4 T% ZP
Specify color of color thru tile: rr��L� M
Submittal Fee,$ Permit Fee $ 3! �J '' w CCF $ (a, , CD co/cc $•
Scanning Fee $ 1 2- • Q5C) Radon Fee $ 4, lPj (�/ Q DBPR $ '1 , Notary $
6
Technology Fee$ t • � Training/Education Fee$ 14• �l� —Double
Structural Reviews $� 7 Bond $ S rWl . a)*4� �i k tJS M%3 ' s • CO TOTAL FEE NOW DUE $ 403C
(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
Zip
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 pasted notice, the
inspection will not 7pproved and a reinspection fee will be charged.
Signature i JAI Signature !�6/
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of n 20 --YL� by
rK4 who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
The foregoing instrument was acknowledged before me this
_a�day of J 174WqZ�e 20 16 . by
.1:60A4 Lladiel) who is personally known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
as
rrC=tc-,C> Sign:
''- V' Print: o r T VR ✓L�
Seal: MARUASSUNTAFEARARo
.; MY COMMISSION# FF082444
:.a EXPIRES: February 13, 201B
i '•xwr„ Bonded nw NdM/PYNb UMen�#ers l
)miner
Zoning
(Revised02/24/2014)
Structural Review
Clerk