RF-05-23-1231 CanceledMiami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
1 30 7 S 220 F 305 756 8972
MAY 16 2023
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2014
BUILDING CANCELLEL) Master Permit No. f?*-as -27 —123 I
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
Sub Permit No.
ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR /) DRAWINGS
JOB ADDRESS: 11361 n' " 0 _ CA �_ _ Ax
Occupancy Type:
Load:
Construction Type:
Historically Designated: Yes
-food Zone: BFE: _
NO
FFE:
OWNER: Name (Fee Simple Titleholder): I I.) I L-L•L Phone#:7 —Z1k—k5_7
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Address:
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City: /" ` I CA 1
State:
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Tenant/Lessee Name:
Email:~?
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CONTRACTOR: Company Name:
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Address:
1
Email: f Li
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Qualifier Name: f, I roA
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/yam" z
(3) Z
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State Certification or Registration #:
l..lL J
DESIGNER: Architect/Engineer:
Value of Work forthis Permit:
Type of Work: ❑ Addition
Description of Work:
d
❑ Alteration
1 '0 — 0 ,,"
-i5Z 7-,b5-j-3
of Competency M
City: State: Zip:
_Square/Linear Footage of Work: G
❑ New Repair/Replace ❑ Demolition
/fie ) _ 1 �91 ./ /7.1 , //
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $_
Scanning Fee $ DCA Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $ P&Z Review $
CO/cc $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised04/05/2022)
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
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 reinspection fee will be charged.
Signatu41(
reP -
Signature
OWNER or AGENT
The f regoing instrument was acknowledged before me this
day of 20 . by
(� tU Writ I who is personally known to
me or who has produced Wz as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal:
4n
CONTRACTOR
TheforegoingInstrument was acknowledged before me this
l U day of MCI20. , by
is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
�4
Sign: Tc)
(I�1/I
Print: 444\ 1 v�LC
Seal:
czozrz u► � s-OAX 3
96CtC6 oo Ucisstwuso3 tiW (N-A
t mv_c�o 'fAmn'r-r- 131
Wi0i� Auu4or •�c: Notary Pubfic state of %rida
epuoi;, ac atE15')l10nc 1U rlc;4 .toRrmy Flores
k4
APPROVED BY
Plans Examiner
Zoning
(Revised04/05/2022)
Structural Review
Clerk