RC-10-727511h
BUILDING
PERMIT APPLICATION
FBC 20
Miami Shores Village
Building D epartment
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
ROOFING
Permit Typ ?,�, p
Owner's Name (Fee Simple Titleholder) Q \ Q .I Phone # J0 r • J q 3 — 1
Owner's Address 0 / g J d t- 1 14k
Tenant/Lessee Name
l ti �1 ``;
Email
Contractor's Company Name
Contractor's Address
City
Qu lifier Name
Contact Phone
Value of Work For this Permit $
Type of Work: ❑Addition
Describe Work:
* * * * * * * * * *''*``)* * * * * ** !' * * * * * * ** 0 *
4 5 Submittal Fee $� l�
Notary $
Scanning $ 1 S
Double Fee $
Structural Review. $
60, v
State
NIA
Radon $ 0'
State
Job Address (where 1c13'' )Jeing done) .S ? ne1
Is Building Historically Designated YES NO
City Miamio'res Village p► County _ Miami -Dade
FOLIO / PARCEL # L i '" aa.3 a i _ p ems► • o3
x
Zip X31
Phone #
Phone #
BY:
Flood Zone /\ E
1
APR Z 8 . �`_�
Permit No. ( RC 10 `�' 7 21
Master Permit No.
Zip
Zip
Phone #
State Certificate or Registration No. Certificate of Competency No.
E -mail
"Engineer's Name (if applicable) ( 4,6 .5 6t th res + btea Phone # 3 Cqh L &C
5 , 10-13-0 Square / Linosixfootagepf 8V k: 150
['Alteration ❑New EI Repairr/Repiace ❑ Demolition
i
('!!F7I7r_riikk u` %dr
k A as ,/.1—c/ a V•
aritit
ees * * * * ** * * * * ** * * * *! * * * * * * * * * * * * * * * * * * * * * ** 1
4 n2-Aval
Permit Fee $ if CCF $ 5 CO /CC $
Training/Education Fee $ Technology Fee $ T GO
Violation date:
DPBR $ 0-15
Bond $
Total Fee Now Due $ aoq.En.,
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 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 estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lie brochure will be delivered to the person
whose property is subject to attachment. Also a certified copy of the recorded notii ;4 o- mencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building peri( is u In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Owner or Agent -w y
e2
The The foregoing instrument was acknowledged before this
day of A92 L , 20 ! , by rn ,
who is personally known to me or who has produced P t j T
L416 054 (T' 217 6, As identification and who did take an oath.
`� s.° � 31VIs ' ''1s, ,�� ullt
.\ � ����� env
s
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
(Revised 07 /10 /07)(Revised 06/10/2009)
\7i!//!G, 40/o ! O,
Engineer
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 _ , by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
APPROVED BY > 13 /4/fi s !j(G 'fans Examiner Zoning
Clerk checked
December 9, 2010
Miami Shares
u I
JLJ1 Nit, 1 Iltri itVr. 1V1111111.1. r .)1)* 4IUD lag,
Departraent
Please cancel permit # RCA. to-727. Work was never started-
Sincerely yours.
- Thok G
WEAVE