REV-16-2519, 474 NE 95th StI �S Miami Shores Village [110jTLY
�°v�Yv
�o Building 32016u dung 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 ' C-tH
FBC 20 N
BUILDING Master Permit No. t-y -5 -/�K
PERMIT APPLICATION Sub Permit No.x �A
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: t+ ` —1
77
,r
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: '�Construc�tion Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): r /e ru�' 2 Y1 O0-04�-j Phone#: 3 ° 5—2-V-2,,-3�
Address:
City: State: Zip:
Tenant/Lessee Name: �% Phone#:
Email: &-.S Yt'- G /.1-u l;0 ZA!z -o :it _
CONTRACTOR: Company Name:
Address:
City:
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $
Type of Work: ❑ Addition
❑ Alteration
Description of Work:
te:
Phone#:
Zip:
Phone#:
Certificate of Competency #:
hone#:
City:
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace
State: Zip:
/'�-
Iola ,ten .'5 '�4 -1
❑ Demolition
,�j � y1l/ S� )D F ori/ Uyt-G �✓vi e �i.� ,�iL�Giy.'1 (Y �a
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ S CT - r> CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $ iJyv
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $ f' /
TOTAL FEE NOW DUE $ �i ' w
(RPviSPdni/')4/7nl4)
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. 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.
Signature Signature
/. -,— OWNE r AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
.1 3 day of S 41F-1-' j"i(:�Fe 20 1 G by
who is personally known to
me or who has produced \r--G U(1KN st as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: �\}
Print:
Seal
�,qs+ Fae, Notary '' : ;ic State of Florida
v _ Q(V Con Eression FF 156750
AUa Q
APPROVED BY
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:
Plans Examiner
as
Zoning
l oo.;-4n,)/'n hni A
Structural Review
Clerk
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12'
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edroom
12.5'
4'
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Un
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Family
5'
Bath
Bedroom
room
Kitchen
Living
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Garage
Dieting
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