PLC-03-18-826 CanceledMiami Shores Village
Building Department MAR AAs��zo�s
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 6+4)
replaces by QI_C-10- Iq- 054�3 FBC 200
BUILDING � CL EbMaster Permit No.y QA —��
PERMIT APPLICATION
Sub Permit No.
OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 9710 NE 2nd Avenue
City' Miami Shores County:
Miami Dade Zip:
Folio/Parcel#:11-3206-013-2350
Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: X BFE: FFE: 11.03
OWNER: Name (Fee Simple Titleholder): Gladys Matz
Phone#: 305-525-8816
Address:714 NE 59th Street
City: Miami State:
Florida Zip: 33137
Tenant/Lessee Name:
Phone#:�
Email: gladysmatz@aol.com
CONTRACTOR: Company Name: Rodrigo Garcia
Phone#: 305-264-3609
Address: 11325 SW 46th Street
City: Miami State:
Florida zip: 33165
Qualifier Name: Rodrigo Garcia
Phone#: 305-264-3609
State Certification or Registration #: CFC1428827
Certificate of Competency #:
✓n
DESIGNER: Arch itect/Engineer: Richard B. BOchnoyich Phone 305-378-5555
Address:10700 N Kendall Drive, Suite 400
City: Miami State: FL zip, 33176
Value of Work for this Permit: $ 7,500
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑■ Alteration
❑ New ❑ Repair/Replace ❑ Demolition
Description of work: Connect existing sewer line to Miami Shores Pump Station #1349
Specify color of color thru tile:
Submittal Fee $ S I d Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/Cc $
DBPR $ Notary $
Double Fee $
Bond $
IRevised02/24/20141
TOTAL FEE NOW DUE $
Bonding Company's Name (If applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (If applicable)
Mortgage Lenders Address
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 on estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien low brochure will be delivered to the person
whose property Is subject to attachment. Also, a cert/fled copy of the recorded notice of commencement must be posted of the job site
for the first Inspection which occurs seven (71 days after the building permit Is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspectlon fee will be charged.
Signature Signature
OWN ar AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
.29 day of /'tit L 20 /8 by
gilodt who is personally known to
me or wighas produced as
identification and who did take an oath.
NOTARY
Print:
Seal:
APPROVED BY
1Revlseda2/24/20141
The foregoing Instrumer/�t was acknowledged before me this
day of Jb./Q( .20IP .by
who Is personally known to
me or wh has produced as
Identification and who did take an oath.
NOTARY PU61IC
Sign
Notary Public Atate uI Florida �y Seal:
My Comm. Expires Jul 27. 2018
Commission s FF 145250
Plans Examiner
Structural Review
V. BERG
My Comdf Expires Jul 27, 201B
Commission p FF 145250
Bonded Through National NOIary Assn.
Zoning
Clerk