RF-02-19-373 Canceled2�1q�'\�� Miami Shores Village RECEIVED
Bulldtlng DepartmAvenue, Miami Shores, lent8
FEB 19 1019
10050
da
Tel: (305) 795-2204 Fax: (305) 756-8972 1
`i INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC
BUILDING CAI�CELLE aster Permit No. �O�
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
G/ (�,CONTRACTOR DRAWINGS
JOB ADDRESS: '"
{ I I I M5kere 0C
City: Miami Shores County: Miami Dade Zip: 3 3 3
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: �7 �t FIFE:
OWNER: Name (Fee Simple Titleholder)): `J1PCA +i� 1 Phone#: f b/ dd % 5f Z
m
Address: I I T-0 _ /1 type v/�,2 �—
City:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address:
City:
Qualifier Name:
State Certification or Registration #
DESIGNER: Architect/Engineer:
Value of Work for this Permit:
Type of Work: ❑ Addition
Description of Work:
State:
of Competency #:
33131
�1 2 City: State: Zip: C,
Square/Linear Footage of Work: r 'T
❑ COO
(� ❑ New Repair/Replace ❑ Demolition ,
Dann \ dO few Y G n A 4 r i'G /hOr t G � ( em%4 C 'oc � .
Specify color of color thru
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $_
DBPR $
CO/CC $
Notary $ - «�
Double Fee $
Bond $ '/
TOTAL FEE NOW DUE $ I I '�F0
(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
W
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 valuf 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 a reinspection fee will be charged.
Signature Signature
ERor AGENT CONTRACTOR
The foregoing instrument wass'acknowledged before me this
day of F�"� 20 j 1 ,by
Di 1._(o O C04�J021, who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal:
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
—W# 1111111N�"
L
APPROVED BY Plans Examiner Zoning
Structural Review
(Revised02/24/2014)
Clerk