RF-09-1272BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle): Building Roofing
0 ... Phone # G 9� 1 795
Owner's Name (Fee Simple Titleholder)
Owner's Address =�
Cityi ;( w
Tenant/Lessee Name Phone #
Job Address (where the work is being done)
City Miami Shores Village
FOLIO / PARCEL #
Contractor's Address . // 3
City 4 "
Qualifier Name 2 /'t
Type of Work: ❑Addition
Describe Work:
CI( * t
JUL 2 9 PA !
Submittal Fee $
Notary $
Scanning $
Bond $
Structural Review. $
k
State Zip t v;
Value of Work For this Permit $
Is Building Historically Designated YES
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
County Miami -Dade Zip
", r
BY:
Contractor's Company Name'4d ''I &-2 < Phone # 7/4 —
State Zip ,..1.341
`
G �° 7 I< , e Fe
#7�4 "4 1' �1
❑Alteration
Square / Linear Footage Of Work:
❑New
Repair/Replace
JUL 2 9 2009 J
Permit No. ` ` 1 t ►
Master Permit No.
State Certificate or Registration No £ C /3? c3' s 7 Certificate o o ritkncy No
Architect/Engineer's Name (if applicable) Phone #
30C
❑ Demolition
*** ** * * * * * *** * * * * * * * * * * * * * *** * * * ** F ** * * ** * * * * *:* * * * * ** * *** * * *** * **
Permit Fee $
Training/Education Fee $
Radon $
Code Enforcement $
DPBR $
CCF $
Technology Fee $
Zoning $
Double Fee $
See Reverse side -
CO /CC
ee Now Due $
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 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 estimate ue exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction li law brochure will be delivered to the person
whose property is subject to attacy ne11r' \Also, a certified copy of the recorded nod e of commencement must be posted at the job site
for the first inspection which ccurs seven (7) days after the building permit is iss ed. In the absence of such posted notice, the
inspection will not bfappro ed and a refnspection fee will be charged.
Signature
Owner or Agent
ment was ackn wledged e e me his O� The fore
da of u , 20 by day of
w t o
is personally known to m
t.- - As c .
NOTARY PUBLIC
Aliiiiiii
Sign:
Print:
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My Commission Expires �BLIG .o Q My Commission Ex
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *' • ♦ ' .
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(Revised 07/10/07)
as produced
nd who did take an oath. 4 01 -
01‘‘,‘ oft t 111 l l l // / � f �.
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Signa
Sign:
Print:
Co tractor
ing instrument w ackno edged b or me tzis
i.Vvv��
20 by ,.-r. Ll '
NOTARY P
as ide
APPLICATION APPROVED BY:
who is personally known to me or who has produced
who did take an oath.
t_%1 1111111104
. —
No. no 473416 200tt
4,r +F
Plans Examiner
Engineer
Zoning