RC-06-2336Tenant/Lessee Name
BUILDING
PERMIT APPLICATIO
FBC 2004
Permit Type (circle):
Contractor's Company Name
Contractor's Address
City
Qualifier Name
Architect/Engineer's Name (if applicable)
Type of Work:
Describe Work:
[]Addition
Submittal Fee $
Notary $
Scanning $ Radon $
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fa • 05) 756.8972
Permit Fee $
Miami Shores Village
Building Department
Owner's Name (Fee Simple Titleholder
Owner's Address
City 1 6190 Ire4 State ¢ �'
Job Address (where the work is being done) '.S6 1 # ki) ri 4) (
City Miami Shores Village County Miami -Dade Zip 33 / 5 6
✓� n bi _ .� . > a
FOLIO / PARCEL # 11
Is Building Historically Designated YES
1u t&(
State
Value of Work For this Permit $ q 0 0
Alteration
MI6
NO
Training/Education Fee $
Bond $ Code Enforcement $
Structural Review. $
Electrical Plumbing Mechanical
❑New
DPBR $
t
Phone # ` $ qiiha_geff5
Zip 5 156
Phone #
Permit No. L O( - 2 2 o
Master Permit No
Double Fee $
Phone #
,, Zip
;Pji one #
State Certificate or Registration No. Certificate of C
etency No.
Square / Linear Footage Of Work:
Repair/Replace
Total Fee Now Due $
S
Roofing
❑ Demolition
*, *** * * * *, * , * * , ** * ** * * * * ** * * * * *** * F *, *** * * * ** * * * * * *, * * * ** * * *** *** ** * ** * **
CCF $ CO /CC
Technology Fee $
Zoning $
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 YOUR PROPER((7fl 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 estamajrdvalue exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien`1a y, will be delivered to the person
whose property is subject to attac ent. Also, a certified copy of the recorded notice of comrtreri must be posted at the job site
seven for the first inspection which o s (7) days after the building permit is issued In ihe of such posted notice, the
inspection will t be approved a a section fee will be charged
1
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this 1� The foregoing instrument was acknowledged before me this
day of , 20 , by IQ vlk(db " , day of ,20_,by
who is personally known to me or who has produced 19lvQ/rf l IC who is personally known to me or who has produced
As identification and who did take an o as identification and who did take an oath.
NOTARY PUBLIC: pp9�� NOTARY PUBLIC:
Ole
Sign:„•\O Sign:
Print /
• `�� � � � �°� Print:
My Commission Expires:
My Commission Expires:
****** * * * * * *** *,* * * ** * *,* * * *,* *** * * **
APPLICATION APPROVED BY:
(Revised 02/08/06)
Signature
Plans Examiner
Engineer
Zoning
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VO/ 4,41 c,317, 1
MAR 2 2007,
BOAS) ........