BP-05-795 (2)BUILDING
PERMIT APPLICATIO
FBC 2001
Permit Type (circle):
Owner's Name (Fee Simple Titleholder)
Owner's Address (OCI 10 46 to
City (a t A r ( S A State --
Tenant/Lessee Name N/ fk
Job Address (where the work is being done) 1 06 1 0
City Miami Shores Village
Is Building Historically Designated YES
Contractor's Address
City
Qualifier
State Certificate or Registration No.
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit ajacQ
Type of Work: DAddition
Describe Work: o(J CI T4
Subinittal Fee $
Notary $ ' Training/Education Fee $
Scanning $
Code Enforcement $
Total Fee Now Due $
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Building
ED
AIL
❑Alteration
Contractor's Company Name WA SC-Lr l Yl o # /•/
[Pflew
Zip 33 13 �f
Phone # /V/ R
I4( Lf 1.. S '
Permit No. 2 Fo e /
Master Permit No.
ing Mechanical Roofing
Phone # 30 I (7- ( 1 l
Phone #
Square Footage Of Work; l {(, LC Irk
El Repair/Replace
❑ Demolition
****************************F
Permit Fee $ 3 J • CCF $
fry `• wee
CO /CC
Technology Fee $
Radon $ Zoning Bond $
Structural Plan Review. $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
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 build' ed value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of mei e i c -- .suction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a d 30 the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) deer 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
Signatur
Owner or Agent
The foregoing instrument was acknowledged before one this 14
20 05, by Jenne 1 C4SN
known to me or who has produced T'D
day of
who is personall
As identification and who did take an oath.
NOTARY P C: c `�` `,
Sign: Cit.- Expires: Ju 3, 200
° ndcd Thru
Print: I ( I , �) ' "ntir Bonding Cr
My Commission Expires:
My Commission Expires:
******************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
Chc 05/13/03
Signature
Zip
//e04'
0)(6.1 11/1/05'
Plans Examiner
Engineer
Zoning
Contractor
The foregoing instrument was acknowledged before me this
day of ,20by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
*********** t****/****** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **