PT-06-2714BUILDING
cr-A lit* Miami Shores Village
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PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Owner's Name (Fee Simple
Owner's Address
City tV1 l MIA
Tenant/Lessee Name
Contractor's Company Name
Contractor's Address
w Building Department
1 0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
r Anlir ar _
State
Job Address (where the work is being done) /1) f 2 v 42 G'4 / A c''
City Miami Shores Village County . Miami -Dade Zip
73/36
FOLIO / PARCEL #
Is Building Historically Designated YES
Architect/Engineer's Name (if applicable)
ouAnti
Value of Work For this Permit $ 15 60
E�
‘ ; 1
City State
Qualifier Name
State Certificate or Registration No. Certificat
Type of Work: OAddition OAlteration ONew
Describe Work:
Submittal Fee $
Notary $ '3'00 Training/Education Fee $ C0 , 29 .
Scanning $
Bond $
Code Enforcement $
Master Permit No.
Electrical n Plumbing Mechanical
Roofing
# 7 � 556 J �/ a
Sr
Zip 7/_
Phone #
Phone #
FT Permit No. 0 6 �I
Radon $ DPBR $ Zoning $
Double Fee $
Structural Review. $ Total Fee Now Due $
NavmEwmi
e Y: ht tk.
Zip
/ hone #
Square / Linear Footage Of Work:
R epair/Replace O Demolition
r******** * * * * *** ** * * ** **** * *** * * % * *** s ************* ** * ** * ** *** **** ** * * * ** ** ** * * ***
Permit Fee $ li - CCF $ Ok CO /CC
Technology Fee $ g•')
e
See Reverse side -+
Bonding Company's Name (if applicable)
Bonding Company's Address
State Zip
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 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 built ermit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement d- construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy o lorded notice of commencement must be posted at the job site
for the first inspection wh occurs seven (7) days after the buil p mit is issued. In the absence of such posted notice, the
inspection will not be and a reins p will be charged.
The for _oing instrument was ac
day of � ,`; .�' (20 by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oa as identification and who did take an oath.
NOTARY PUBLIC: o \y 995 NOTARY PUBLIC:
sP oo
Sign:
Print:
My Commission Expires:
APPLICATION APPROVED BY:
(Revised 02/08/06)
1 9
Contractor
The foregoing 'Ms er was acknowledged before me this
yof ,20,by
Sign:
Print:
My Commission Expires:
csa
.•
Plans Examiner
Engineer
Zoning
4
1
All elements on the site must be listed and indicate the color to be painted
Walls: a.64 CI(?
Fascia: / ,0 r0 V 1 C -eat k 10
Drip Cap/Drip Edge:
Soffit:
Roof:
Date: Owner's Name: L)LId 40)5691V Phon #: l a 55 > a4
Job Address (where the work is being done): /lo ie t ,4 u' e_
City: Miami Shores Village County: Miami -Dade Zip:
Is Building Historically Designated ?: YES
Contractor's Company Name (if applicable):
Flower Bins:
Shutters:
Awnings:
Chimney:
• Miami Shores Village
Paint Color Approval and Agreement
Doors and Door Jams:
Garage Doors:
Railings:
Fences:
Decorative Metal:
All brick (simulated or regular):
Stucco Banding:
Any other Stucco Features:
Accessory Buildings:
Other:
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in compliance ,`xT.11 applicabs regulating construction and zoning.
/
Signature: Date:
0 er or Agent
APPLICATION APPROVED BY:
f P & Z OFFICIAL
NO
Phone #:
Date: /l1'*
* *MUST BE ATTACHED WITH PURPLE BUILDING APPLICATION **