REV-12-19-2983, 1275 NE 103StMiami Shores Village ClkvED
Building Department JAN 2 8 020
10050 N.E.2nd Avenue, Miami Shores, Florida 3313E BY:
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING Master Permit No.&P-0-1q —07
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING XREVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores //�� County: Miami Dade Zip: ✓� 13 C)
Folio/Parcel#: l' " 32D5 -O�o " DOD Is the Building Historically Designated: Yes NO
Occupancy Type:6fA2-- Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple TiitljjTitleholder):r): �- �6�C.. JQiiamIin Phone#:
Address,: tV
11 1
City: IJaM I S � State:' (• Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 0A L f,5o �z1 me e Phone#: ' "" /39" / v
Addres • rblJ/
City: Ce,'State: Zip:
Qualifier Name: `\� Phone#:
State Certification or Registration #: lLP(:i 075 7.9 Certificate of Competency #:
nge---�--
DESIGNER: Architect/En er: AAI+F )O I O CA �n e LAS Phone#: 2
Address: 1 _ City: � 1 IJAM) State: � Zip: —3
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: 51
Addition ❑ Alteration
*0
❑ New
-e
❑ Repair/Replace ❑ ((Deemolitionf� /`/� - f D
O/ C() V1 A 1 vf�
Description of Work:
I v Q U ( L�.T
�1�• Si
Q S 1JE.TA I L— = /
2. CHILD
Fr,-NGE AS [3ylLT
E'WZ
jdoL� &ARRi C Q,
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF $
DBPR $
CO/CC $ -
Notary $,
Double Fee $ _
Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE $ J 'I —1 . 60
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 co. mencement must be posted at the job site
for the first inspection which occurs even (7) days after the building permit is issue In th Bence of such posted notice, the
inspection will no16-e ed and ",seven
fee will be charged. r n 77
Signature
R or AGENT
The foregoing instrument was acknowledged before me this
O�h day of , 20 z6 , by
6W 1 n, whovs personally known to
me or who has produced as
identification -and who did take an oath.
NOTARY
Sign
Print:
Seal: � - ` :, Commission $ 60 290679
=; is Expires JenuM 13. 2023
Bonded TNm Troy Fain Insurance 8004WT019
Signat
R
The foregoing instru nt was acknowledged before me this
!�� day of 14M +% 20 �Z6 by
�iJ►�✓ E�✓D1>wX-'A- Ywho i� ers ally kn�own t
me or who has produced as
identification and who.Gi�ake an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: IF
APPROVED BY I ✓ (�Plans Examiner
WLLIE D. PEMCHET
WCOAMMS MSOG29030
EXPIRES: Apri 14► 2023
Bonded Tiw Notary Puhlc 11adr�wter
**************
Zoning
Structural Review
(Revised02/24/2014)
Clerk