RF-03-22-543 CanceledMiami Shores Village rRECETVED
Building Department i,11R pI Z002Z
CANCELLED
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
055-2204 Fax: wIRFo3 � �C7 INSPETel: (3 LINE)79PHONE NUMBER) (305) 756-8972-4949 By: �—
_IFBC 202���
BILDIN6 Master Permit No. �'�' L'3 �Z Z
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ROOFING
Sub Permit
❑ REVISION ❑ EXTENSION DRENEWAL
❑PLUMBING ❑ MECHANICAL 0 PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: S6 0
City: Miami Shores County: Miami Dade Zip: 33 13-F
Folio/Parcel#: 1 I — ?t,Z?f, - O 1 LA - i 0 ba Is the Building Historically 1D^�esiignated: YesNO
Occupancy Type: t- F' Load: 0 Construction Type: %Ut Flood Zone: NY-1't BFE: t� �- FIFE:
OWNER: Name (Fee Simple Titleholder):�4aocji Lk Phone#:
City: Wi Q U':� S kar a-, State:
Tenant/Lessee Name:
CONTRACTOR: Company Name: I!/\ V
Address:
City: e p
Qualifier Name: ! (A)
State Certification or Registration #:
DESIGNER: Architect/Engineer:
3 )38
(Po+45-AyGEzo1330C':,
.C" Phone#: q-r (-/ �4/0 6yb/, Y
of Competency #:
Zip: /
0-3
Value of Work for this Permit: $ �n G 4c-,' Square/Linear Footage of Work:
Type of Work: ❑ Addition �E Alteration I --]New Repair/Replace ElDemolition
Description of Work: A?,,—(Ieo v` 1F lQ 7sC "mil 1R
Specify color of color thru tile:
�t»
Submittal Fee $� J� Permit Fee $
1
Scanning Fee $ Radon Fee $
Technology Fee $
Structural Reviews $
Training/Education Fee $
CCF $ CO/Cc $
DBPR $
Notary $
Double Fee $
Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE $
Bonding Company s Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lenders 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 low 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 iss In the absence of such posted notice, the
inspection will not be approved and o reinspection fee will be charged.
h �
cab Signature G� Signature �-
.._./// OWNER AGENT
The foregoing instrument was acknowledged before me this
�--dayof �n^2-� 20 by
who is pets wn to
me or who has produced
identification and who did take an oath.
CONTRACTOR
The foregoing instrument was acknowledged before me this
CSL day of 2- ')-- 20 2'Z by
L�S it Li C- a✓J' ) q*ho is per known to
as ,me or who has produced
identification and who did take an oath.
as
NOTARY PUBLIC: "U`o'� '�Woo �{yy NOTARY PUBLIC: ZZOzt x3
nee noa SWOr 11016199 I"kAl
.G uppow 10 e0a3 allgnd e1oN / /,.%��� n6a it e60or
Sign: Sign: cCf—"` 6pUgd M RS oIP ��t
Print: Print: 0 r P C,
Seal: Seal:
APPROVED BY S- L Plans Examiner
Zoning
Structural Review
(Revised02/24/2014)
Clerk
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