BP-04-503P,
Miami Shores Village
- Building Department a(tt co
4 2194 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILM
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building Electrical Plumbing Mechanical
Owner's Name (Fee Simple Titleholder) A e /Ylfr� L /V//t'S Phone #
Owner's Address /9 o/ /v6- /21 Q& /
City /1 „ State Zip 3J(..8
Tenant/Lessee Name Phone # SO.5 75/— /,3 �✓
Job Address (where the work is being done) ,54772 G1 Gn
City Miami Shores Village Cot i y i Miami -Dade Zip
Is Building Historically Designated YESi ;
l
Contractor's Company Name at hone #
/
Contractor's Address > i'>
City State ,4,4,i
yy
Qualifier
Architect/Engineer's Name (if applicable) Phone #
1 7 ( $ Value of Work For this Permit j ) (:2 O Square Footage Of Work:
Type of Work: DAddition ['Alteration ❑New IrRepair/Replace ❑ Demolition
Describe Work: newt 2 ( Oi /1 /doof iv 1i a-e-
4e/2and
Submittal Fee !� 0 a Permit Fee $
Notary $ 5 1--- Training/Education Fee $
Scanning $
7
Radon $ Zoning
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $ c 1
(Continued on opposite side)
Permit No,P Q‘ D 5 ��
Master Permit No.
3OS /.51y
CCF $ , 4,0 CO /CC
Technology Fee $ ? r 5
Bond $
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 T-9. YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER R -J AN' ATTORNEY BEFORE RECORDING YOUR NOTICE OF
L /(( i/:
Aronce to Applicant: As a condition to the issuance of a building mit'w rth gra estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and don str ghoq' law brochure will be delivered to the person
whose property is subject to attachment Also, a certified copy of the recorded -ti ce-o mencement must be posted at the job site
for the first inspection which occurs seven (7) days after the rag permit is is n the absence of such posted notice, the
inspection will o be approved and a reinspection jee will be charged.
COMMENCEMENT."
Signature 6v OrGal 6,17
Own or Agent Contractor
The going instrument was . owledged before me this ) f The foregoing instrument was acknowledged before me this
da - ;I__... / 20 Y, by day of , 20 —, by
r
w r o is • ersonally known to me or who has produced who is personally known to me or who has produced
identification and who did take an oath. as identification and who did take an oath.
NOT " PUBL C: j / NOTARY PUBLIC:
I
Prin Print:
My Commission Expires: My Commission Expires:
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
************************ *** *** * * * * * * * * * * * ** * * * * * * *** *V * *, *************** ** * *** * * * ** * * * * * * * * * * * * * * ** * * **
APR 2 5 2004
APPLICATION APPROVED BY:
Chc 12/15/03
Signature
Plans Examiner
Engineer
Zoning