WS-10-520‘)\\`',
BUILDING
PERMIT APPLICATION
FBC 20
Contractor's Company Name
Contractor's Address
Value of Work For this Permit $
Type of Work: DAd
Work:
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 3313
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit Type (circle): Building Rooting
Owner's Name (Fee Simple Titleholder) Da r L . 1-1 - 6
Owner's Address '� 1
City 1 ter t S ►- Zc'� State Zip 33 4SO- QQ- 4
Tenant/Lessee Name rr��
Phone # 4°� 1 ; -- ) cS 40 '1
Email ■■ E.AD'NC; r 4 l) IA , - D .
Job Address (where the work is being done) .9 '1 NUJ 4 . " p )
City Miami Shores Village County Miami -Dade
FOLIO / PARCEL #
YES NO K
Zip 36 i C -a-4(
i
KIN 2 9 2OUf
Permit No
Master Permit No
(3as: G6S
Flod Zone
Phone #
City State Zip
Qualifier Name Phone #
State Certificate or Registration No. Certificate of Competency No.
Contact Phone E -mail
Architect/Engineer's Name (if applicable) }) Phone #
DAlteration
Square / Linear Footage Of Work:
DNew
****** * * * * * * * * * * * * * * * * * *** * * **** * * * ** * Fees****** ** * * * * * * *** * * ** n********
Submittal Fee $ Permit Fee $ CCF $ CO /CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $
Repair/Replace 1 ❑ Demolition
* * * * * * * * * **
Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverie side -*
Bonding Company's Name (if applicable)
Bonding Company's Address
City
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 CONDMONERS, 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 conzmencernent 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.
o
Owner or Agent
The foregoing instrument was acknowledged before me this If
day of ,20 /6 , by P#4AK.4_ /76—/
who is personally known to me or who has produced R--
As identification and who did take an oath.
NOTARY PUBLIC:
Signature
Sign:
Print:
My Commission Expires:
APPLICATION APPROVED BY
(Revised 07110/07)
State
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Plans Examiner
Engineer
-
Zip
Contractor
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:
My Commission Expires:
****
Zoning
Clerk checked
December 2nd, 2010
To Miami Shores Village
Building Department
1 would like to CANCEL the permit number WS 10520 , regarding a
door change, at 9100 NW 1 Avenue, Miami Shores, FL, 33 150, because the
job was never done and it never will.
Thank You!
Daniela L. Motta (owner)
(305) 965 - 7778
roEcartv:
HECO3210
BY: .1
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