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Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING Permit 11o.Di O 1 � ' g70Z
PERMIT APPLICATION Master Permit No. CC,
FBC20
ADMA„ 1\1 gh-1
Permit Type: BUILDING _ROOFJ TG._
Owner's Name (Fee Simple Titleholder) 0121-Pily Cp trECcE Phone # SO4 1 3 4 10,3
Owner's Address U 300 N. 2,ND A■E.f.) vE.
City D'ii R M■ , -1425. State - T 1_048M Zip 331,)(
Tenant/Lessee Name Phone #
Email
i
Job Address (where the work is being done) 1 NI� 2 Q> , N : I ,--)TRAR
City Miami Shores Villa e County Miami -Dade Zip
FOLIO / PARCEL #
Is Building Historically Designated YES NO Flood Zone
Contractor's Company Name i (1 C _ Phone # 75yct 22 -1777
Contractor's Address 19 (.0 t t_5(*) 3T�F 1
Zip Z3oa
City of k Llicrs State s f't.C)' � (4j,4
Qualifier Name CL&J\ Z A K Phone # 7-14-4-1)47-7b
11E0 X
MAR 0 920E
BY: L
State Certificate or Registration No. �'�� 51 p� 2� Certificate of Competency No.
' Contact Phone 75y Lt22. --(77> E -mail r 3 r7u - gy m
:atl iteE rs Name (if app 11 0110111T401212.1 P0?•SACPhone # 95 $DSO
Value of Work For this Permit $ r)(3 .00 Square / Linear Footage Of Work: t (0 6 a r
Type of Work: OAddition
Describe Work:
bill (r 346t7 :itiiu
b�ld.7.
re)e8e n * st ieditumi 3
* *.", *** *„ * * * * * ** * * ** * *,x* *** * * * * * ** Fees ************* * * * *x **. * * * * * * * * ** * *** * * *** * ***
9A 10 Submittal Fee Permit Fee $ 1 °Clea CCF $ 0"(00 CO /CC .$
Notary $ Training/Education Fee $ 02..0 Technology Fee $ 0'O°
Scanning $ Cp 00 Radon $ DPBR $ Bond $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $ 57
See Reverse side —+
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 Y OUR 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 s seven (7) days after the building permit is issued. In the ab of such posted notice, the
inspection will not be -pprov < and a reinspection fee will be charged.
Signature
NOTARY PUBLIC:
Sign: -,k,. 10L.
Print:. L ' . lot
My Commission Expires:
APPROVED BY
Owner or Agent
The foregoing instrument was acknowledged before me this /(c
day of 24
who is2ersonallv known to me or who has produced
As identification and who did take an oath.
(Revised 07 /10 /07)(Revised 06/10/2009)
52t/CF =F flS Signature
,• °°"•,, LINDA S. MITTS
VI Notary Public - State of Florida
1 My Comm. Expires Jun to, zu13
4 Commisslon dt DD 883031
r flood Through National Notary Aun.
AINO. AM,
2 6 iD Plans Examiner
Engineer
tracto
Co
The foregoing instrument was ac ,.. owl ged before me this 09
! `• :!fie °- Veal , 20 [4_, , y 100 6 ,
who is personally known to me or has produced
as id
NOTARY PUB
Sign: ,. '116 b
Print:
My Conu ion Expires: 0s/1S /ZCl
Zoning
Clerk checked