REV-10-19-2457, 716 NE 92nd StMiami 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 1-+
BUILDING
Master Permit No. ' -
PERMIT APPLICATION
Sub Permit No.Pey-
❑BUILDING ELECTRIC
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL
❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
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JOB ADDRESS:
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City: Miami Shores
County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type: Flood Zone: BFE: FFE:
Titleholder): E :�t,� c[o 0 � Ot L odL Phone#:
OWNER: (Fee Simple Tl
yN,aam�e
Address,�I/0�C,- F l !
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City: f ) ( CA_r�I
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State: Zip:
Tenant/Lessee Name:
Phone#:
Email:
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CONTRACT R: Company N e:
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Phhone#:
9
Address: `
City: -
State: Zip: c3-30 1
Qualifier Name:
Phone#:
State Certification or Registration #: l �l1 �`)!l5 "t . Certificate of Competency M
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Additi n 1 ([x] Alteration /�� � ❑nNew ❑ Repair/Replace ❑ Demolition
Description of Work: �/ w5(() � W b IY -e i �eC S CGhn✓ j-eA�
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $_
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ Q
(Revised02/24/2014)
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. A A
Signature Signatu
OWNER or ALNT
The foregoing instrument was acknowledged before me this The foregoing instrum�elntt was {aackkno,�wledged befor a this
day of� 20 I by I � day of l.�l.d/�-� , 20 by
UEVO GZhe i ersonally known to VA�who is pe onally k n to
me or who has produced as me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
OJ4—
Sign: %�'%� ,1 j
Print: O nImo/� "` ` - v
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: ,•��bv'?s%,,, Blanca L. Moreno Seal: ,�P
`r= Commission # GG129380 s«.
:._ _
- Expires: July 30 2021 -� v
APPROVED BY Plans Examiner
8kr a L. Moreno
F= Commission # GG129380
*= Expires: July 30.2021
Bonded thru Aaron Notary
Zoning
Structural Review
(Revised02/24/2014)
Clerk