DS-10-23-2634 CanceledMiami Shores Village MN'IC1^RED
Building Department DEC 21 ,_o,
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 1'
CTel: (305) 795-2204 Fax: (305) 756-8972 BY: t{
AN�ISPECTI N LINE ONE NUMBER: (305) 762 4949
CELLE FBC 20
BUILDING Master Permit No. DS10-23-2634
PERMIT APPLICATION sub Permit No.
®BUILDING ® ELECTRIC ® ROOFING ® REVISION ® EXTENSION ®RENEWAL
PLUMBING ® MECHANICAL CHANGE OF Ia CANCELLATION ® SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 29 NE 109 Street
City: Miami Shores County: Miami Dade Zio:33161
folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: I Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titlehnlderl,Jaequellne Gonzalez Phnnp#.305-281-8409
Address:219 NE 109 street
City: Miami
Tenant/Lessee Name:
Email:
State:
CONTRACTOR: Company Name: Erick Medina
Address:
Florida 7;,,.33161
Email:
Qualifier Name: Phone
State Certification or Registration #: Certificate of Competency M
DESIGNER: Architect/Engineer: Phone
Address: City:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: I3 Addition ® Alteration ® New ® Repair/Replace
Description of work: Front Drive way
Specify color of color thru
Submittal Fee $
Scanning Fee $ _
Technology Fee $_
Structural Reviews
Permit Fee $
DCA Fee $
Training/Education Fee $
CCF
DBPR $
P&Z Review $
Zip:
® Demolition
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revisedo4/05/2022)
Bonding Company's Name (if applicable) _
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
0
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 approv and a nspedion fee will be charged.
Signature Signature
OWNER or AGEN CONTRACTOR
The foregoing instrument was ack owledged before me this
I day of be-Y' , 20 2-3 , by
who is personal) known to
me or who has produced ! ✓5�l l
identification and who did take an oath.
NOTARY PUBLIC: %wily. �'" Jem � elaMcDowell
m COIRm.:HH285819
Sign
Expires: July 10, 2026
, —Y Itfbfic - bl8teof Florida
Print:
The foregoing instrument was acknowledged before me this
day of . 20 by
who is personally known to
me or who has produced as
identification and who did take an oath
NOTARY PUBLIC:
Sign:
Print:
Seal: Seal:
APPROVED BY I� I Plans Examiner Zoning
Structural Review Clerk
(RevlsedU4/05/2022)
Miami Shores Village
`°7 Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
4 I Permit#: PW- 10 -o
Name of Applicant (if utility see below): T. "Ac.� `zrVy;—" �z
Owner off the following described property: %
Legal Description: Lot Block Subdivision
Folio #; - C(o00
Address:
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
CONTRACTOR NAME: N1t3
Qualifier/Authorized Agent:
Email:
State:
ZIP:
of Competency #
Address: iqA rA9 I-4 ST
City: f7-1i0le-.b State: FC_ ZIP: 3306
Telephone: (g-oslz4H- 08314 Email: MPc1b`; 1 uerSCDC P ��croi l-C�i
State Certification or Registration #: Cb C- I SZ.19 160 Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way:
Type of Work: ❑ Paving ❑ utility
❑ Landscape ❑ Antenna
DESIGNER: Architect/Engineer:
Address:
City:
Telephone: _
Registration #:
❑ Sidewalk ❑ Electric ❑ Irrigation
15c1 Other: v f
State:
Email:
PIS
Value of Work for this Permit: $ kUU Square/Lineal Footage of Work: 2 O
***** Fees *****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $
Bonding Company's Name (if applicable):
Bonding Company's Address:
City:
State:
ZIP:
Application is hereby made to obtain a public works permit to do the work in the right of way 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, regulation construction in
this jurisdiction. I understand that separate permits must be secured for
APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in compliance with applicable laws regulating construction and specifically construction in the
right-of-way.
"WARNING TO APPLICANT: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. 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 public works permit with an estimated value
exceeding $2,500, 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 eri I property is subject to the
attachment. Also, a certified copy of the recgcd7f�2� ent must be posted at the job
site for the first inspection which occur sev,���c 11 a public works permit is issued. In the
absence of such posted notice, the inspe on will not be approved and a reinspection will be charged.
Signature
Applic nt or Aut rized Agent
The foregoing instrument was acknowledged before
me this t- day of Ak S 20.2-3 by
who
i{ personally known tome or who asproduced
cliC9Lf C 4(=-0 1z-S /-e- ` as
identification
NOTARY P LIC:
Sign: _—
Print: I rylera / *ride{
SEAL
( Company/Utility Agent
The foregoing I strument a acknowledged before
me this ay of 20". by
1• ;? i?, i/rC% who
is er—so nally known tom or who has produced
as
identification
NOTARY PUBLIC:
Sign:
Print: ✓LOfi�// "' ' '"" ""- t
SEAL:
YP°Bl/° JEARETTEFERNANDEZ
Jamela MMcDowell°'tlR.• .
„°wnrp a = Commissbn8HR12a702
„ . #
Expires May11,2a25
Comm.:HH285819 �,, ee` eawam�ry01arys`"�3
Expires:July10,2026°ram°
'n '� "d •° NotaryPUblipteef#k3ridEs***s*sss**s*ssssssssssssss*s*ss*
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APPROVED BY:
Public Works Director, or Designee
2017-04-15