REV-12-22-3105Miami Shores Village
RV —'MtVED
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
❑PLUMBING ❑ MECHANICAL
JOB ADDRESS:
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 202DIM
Master Permit No. RC- 12 - 21- 33 4 $
Sub Permit No. REY- 12—op o5
❑ ROOFING _R REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
IN . -Rl a -at a-Ve,
City- Miami Shores County: Miami Dade Zip: 3311�
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): fna&A ecr2-ILto, Phone#:: 0SEU 01S
City: - State: _Zip: 23Pp/ Sn
Tenant/Lessee Name: �� Phone#:
Email:�j 04U(a��f1) hff n (I fm(r
CONTRACTOR: Company Name: c.�C-�li I�n ion Cf'o(W Phone#:
Address: -72 (3 FJ W 4F, STN-s�( Mlbr9r I=(- -35 f Cr.,
Email `�sCW "CCw.-I P (3 l • C.�*A
Qualifier Name: T'f')Cwt?, 16 - pavt -L Phone#:
State Certification or Registration #: CGC 5 (y7 ZfkCertificate of Competency M
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: _Zip:
Value of Work for this Permit: $ CYOb _ Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: AckA n rhl i) b OL+V\ Orr-)
Specify color of color thru
Submittal Fee $ _. 'Permit Fee$ 11103 / CCF $ ( CO/CC $
Scanning Fee $ 3(� " DCA Fee $ 2 • O J DBPR $ Notary $ �-
Technology Fee $ (.0 • t�7 Training/Education Fee $ 0 - - J Double Fee:
Structural Reviews $ s P&Z Review $ Bond
TOTAL FEE NOW DUE $
(Revised04/05/2022) 2.10 , (6 D
Bonding Company's Name (if applicable) _
Bonding Compa's ss
City State
M�n�eLs Name (if applicable)
Mortgage er(y��` 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 excee
promise in good faith that a copy of the notice of commencement and construction lien law brochure
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencem
for the first inspection which occurs seven (7) days after the building permit is issued. In the ob�
inspection will not be approved and ad. reinspection fee will be charge
SignatureMu V J , • Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
1Z yddaay'�of 1J - 20?�, by
GL 1cl �/i UJ ..h/ooiispersonally known to
me or who has produced �h ✓cif djQ22Eeas
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: _
Seal: G
APPROVED BY
hg $2500, the applicant must
fill be delivered to the person
must be posted at the job site
-e of such posted notice, the
The foregoing in36u&nt was acknowledged before me this
� �day ofa2zmb ,wZ 20 , by
Wn (g IKJI Y-P/ PZ . who is personally known to
me or who has produced Qn W V i C1104--e"C as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: I I
Seal:
****************
Plans Examiner
MERLINE CHERY
MY COMMISSION M HH 252206
EXPIRES: April 1Z 2026
Zoning
1 IA 1/3 Structural Review
(RevisedD4/05/2022)
Clerk