REV-12-22-3106Miami Shores Village
BUILDING
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
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FBC 2020
Master Permit No. -
PERMIT APPLICATION Sub Permit No. ei / ZZ la4--(
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❑BUILDING ❑ ELECTRIC ❑ ROOFING ® REVISION ❑ EXTENSION ,,RE& AL 31 hi n
[PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
,Q � �CONTRACTOR DRAWINGS
JOB ADDRESS: -1 �� , , lam, t`ii 0.Ve ))
City Miami Shores County: Miami Dade Zip:
the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Simple Titleholder): `�/10 Phone#: ,
Address: q!M 1 N • fit Q-R\ a r eJ
City: >, (ic 1( ` Orr-S State: IL L Zip:
Tenant/Lessee Name:
Email: mQdiol
CONTRACTOR: Company Name: 5&"I LA<C A-) Czrzi> Phone#: -31b� rOA0 '��9
Address: �('� �W `JTllf � �N of Fc. 33tG45
Email: r�UJ\l,��C-6NF� �1,F'IQw• C'�.0"�
Qualifier Name: Y�Clo3k t& - r-Cm%sz- Phone#: 154, a04 cf+1z
State Certification or Registration #: CfC (4ggG 03 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Value of Work for this Permit:
Square/Linear Footage of Work:
_Zip:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: P, n eu ) bol4kamx ,
Specify color of color thru the:
Submittal Fee $ Permit Fee $ ..1 I `y CCF $ G '� J" CO/CC $
Scanning Fee $ V•y'� DCA Fee $ (� • u`� DBPR $ Z • Notary $
Technology Fee $ 1 • t�� Training/Education Fee $ I . � Double Fee $
Structural Reviews $ er P&Z Review $ Bond $
TOTAL FEE NOW DUE $ l4q.70
(Revised04/05/2022)
Bonding Company's Name (if applicable)
Bonding Corr$an dress
City ,t
State
MoA der's Name (if applicable)
e^+
Mortgage a 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 exAsce
ing 52500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochwill be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencemust be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the a 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 The foregoing instru�ieennt/�waass acknowledged beforemethis
12 day of �'�� U , 20_, by L3 day of I/(_o 1 I13 . 20 Z(� , by
MOV 6, ,rgL,bL/ who is personally known to I v ti v �w�hhoo�iiss personally known to
V1 me or who has produced y iict [-t°i1?s as me or who has produced PVL/
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 1 1yc-/� LT
Print:
Seal:
MERLINECHERY
zs •. MY COMMISSION # HH 252206
N, ,? ' EXPIRES: App 12, 2026
APPROVED BY
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal:
Plans Examiner
MERLINE CHERY
MY COMMISSION # HIM 252208
EXPIRES: Apr# 1$ 2026
Zoning
(Revised04/05/2022)
Structural Review
Clerk