REV-12-22-3157Miami Shores Village
RECElvpD
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
BUILDING
PERMIT APPLICATION
❑BUILDING ® ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: N . T1 Q01 A (
DEC 18 k022
BY:— 4IT
{{FBC 20
Master Permit No.ix(.-I)1-.i3L��
Sub Permit No. 'fit- OB07-01[77—
® REVISION ❑ EXTENSION RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City Miami Shores County: Miami Dade Zip: sAf Sb .
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleh•�ollder):_fi 0 Q t 1, F_V4 U A Phone#: 30sq'lal o
Address: 9%( NII •�,(le-�i aw
City.r (Qi -n 1 ��10 1 f- State: Zip:
Tenant/Lessee Name:
CONTRAtC�TOORR,:: Company Naame:1l).7I
Arirlrp�
Email:
Qualifier
State Certification or Registration #: F—C!�`Z2b DM 2" Certificate of Competency M.
DESIGNER: Architect/Engineer:
Zip:
ar
Value of Work for this Permit: $ oc Square/Linear Footage of Work:
Type of Work: ❑ Addition ® Alteration 1 ^`'�❑ New ❑ Repair/Replace El Demolition
Description of Work:�Qau '�'— hirn
Specify color of color thru tile: ^{'�
Submittal Fee $ __. permit Fee $ 1CCF $_ Ikt 0 , CO/CC $
Scanning Fee $ t3• �137 DCA Fee $ eL . a-', DBPR $ 2 • W Notary $
Technology Fee $ �0' Training/Education Fee $ 0 • � Double Fee $
Structural Reviews $ P&Z Review $ Bond $ TOTAL FEE NOW DUE $ Q 10
(Revised04/05/2022)
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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
1L day of .l�L lS /��' )�l.-T , 20 , by
I, V lQ n G �!4 VQ- v`h/o iis' personally
ykknown
ntto
me or who has produced Dn e d],1��/ 1dC as
identification and who did take an oath.
NOTARY PUBLIC:
Signature y
s ;�,,
CONTRACTOR
The foregoing instrument was acknowledged before me this
_(�dayof JQ0-tW1LQU .20d2; by
who is personally known to
me or who has produced Dill- 553065044 =() as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign:
Print: I ,t 1y Prin Curinc. / Y7ivtd&
Seal: Seal:
µir 10hAM AURANOA
MERLINE CHERY No ary vumk • sate a nw d.
s*: MY COMMISSION#HH252206 comm�pnrnNosnw
s9•. •• ' My Comm. mires Oct 7• ID21
********** EXPIRES:A "12,2026 WIN
APPROVED BY
Plans Examiner Zoning
(Revised04/DS/2022)
Structural Review
Clerk