DS-07-19-1512 CanceledMiami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING CANCELLED
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑
aster Permit No
EIVED
AUG 10 2023
BY:-
FBC 202)' -14"
Sub Permit No.:ff)—C4— lq - I'S12-
�❑ EXTENSION [—]RENEWAL
❑PLUMBING ❑ MECHANICAL ❑ CHANGE OF � CANCELLATION ❑ _SOP
G CONTRACT
R�,,1 DRAWINGS
JOB ADDRESS: Io(o \ c 7- t
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: �t' 22 Is the Building Historically Designated: Yes � � l— kNO
Occupancy Type: Load: Construction Type: r,� 0-Flood Zone: BFE: F�FE:
OWNER: Name (Fee Simple Titleholder): (JJ n— -- Phone#: S-G I —L/(3— d$1Ck
Address: )o(a (q C 1446-, Av--O—�
City: ✓ Af'k M ` UK S State: -CL Zip: `5�:> 1 3
Tenant/Lessee Name:
Email: J v1
«�gNzerc�-ti,
CONTRACTOR: Company Name: t���� C�,�'a.� r`^' Phone#
Address
Email:
;cn( -213-0VU
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: / City: State: _Zip:
Value of Work for this Permit: $ S r - Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New
^o//' 1 1 Repair/Replace c ❑(Dc'--olition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $—
Scanning Fee $ DCA Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews S 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 *at 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.
Signature Signature
0 NER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
t O day of Ay , 2043 , by
VJ2-55-e- ��_Z , who is personally known to
me or who has oroL c- as
The foregoing instrument was acknowlec*6d before me this
day of ,1-11, 20 , by
me or who has produ
who is personally known to
identification and who did take an oath. identification and wO6 did take an oath.
NOTARY PUBLIC: NOTARY PUBLI
as
�J Sign: Sign:
Print: �� V "�h'�- yao
x�o�:. .a�ui�+u,i•,:� -��
Print •
VivienneYao
Seal: S I:Pe%,Comm•:H2a
Expires:Jan. 31,2026
`Notary Public. State of Florida
`\RN
APPROVED BY Plans Examine Zoning
Structural Review Clerk
(Revised04/05/2022)