DGT 8-17-2160 CanceledBUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
Miami 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
FBC 20
Master Permit No.��(i�- 20
❑ ROOFING ❑ REVISION
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF
JOB ADDRESS:
Sub Permit No.
CONTRACTOR
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City:. Miami Shores County: Miami Dade Zip:
❑ RENEWAL
SHOP
DRAWINGS
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type:
Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):, ` brt+'r/`��V �-^y"c �'`-nO'" Phone#� Sty
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City: t Rrw gV'-br
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:`..
Address: • O . SOX
City: V v �cr1
Qualifier Name:
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—Zip. S
3c� 5 Liz, QsLS�t
State Certification or Registrationn ##:�C Q' C- -Q(Ptx'yS Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#.$(�
Address: City: State:Zip:
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Value of Work for this Permit: $ 02 °� m Square/Linear Footage of Work: I
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ Vzo . (:5:) Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
_ CCF $_
_ DBPR $
CO/Cc $ 11 0
Notary$ J
Double Fee $
Bond $ Q
(Revised02/24/2014)
TOTAL FEE NOW DUE $
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
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 IMPROVEME116% TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOURL&IVER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance ing permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notic encement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also ified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven .7) ays after the building permit is issued. In the absence of such posted notice, the
inspection will not
t be approved and a reiinnspecction7n{fee will be charged.
Signature, ( l�'� Signatur��K
����� OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
��✓ day of 20 1 by
aNU�� G�t2n tLLO , who is personally known to
me or who has
identification and who did take an oath.
NOTARY
Seal: 1 =aYj1T 0�a�. Notary Public State of Florida
Sindia Alvarez
%a g° MY Commission FF 156750
or, nQ Expires09/0312016
APPROVED BY
� Z5t i1
(Revised02/24/2014(
The foregoing instrument was acknowledged before me this
2.S day of,At )GUs lI , 20 1 � , by
�NUtt CFAAP�(�Tt"gih�is`personally known to
me or who has produced : i- - �(Z- U-cc::'Eas
identification and who did take an oath.
NOTARY PUBLI
Sign: `-
Print:
o Notary Public State �l =mnda
Seal: � SindiaAlvarez
a My Commission Fr .0750
(-y `er_noap a E.xp'ire_s0.910-312
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Plans Examiner
Structural Review
Zoning
Clerk