PAINTMIAMI SHORES VILLAGE
Alowitrimuti-A.
DATE:
OWNER'S
ADDRESS: 6fir) jJt ( ,S
************************************_ :_ * * * * * * * * * * * * * * * * * * * *__ ** * * * **
ADDRESS OF SITE: 'Sggq_:.
CONTRACTOR & LICENSE (i ap}illc Ne u
COMPANY NAME:
**************************** * * * * * * * *_:_ * * * * * * * * * * * * * * * * * * *_
All Elements n the site must be listed and Indicate the color to be
Walls Elements RC)
Fascia LJh.
Drip Cap/Drip Edge
Soffit u✓ I K
Roof
Flower Bins
Shutters
Awnings
Chimney
Doors and door jams 8 ;-�' C -� )i nu
Garage Doors l-3(, re
Railings
Fences
APPROVED:
Paint Co1or.A1ip1�Qv�•3I3 Agreement
Agreeme t • . :44 �: :
• • ••• • • • • •••
Buil ing O ffi ial
ritt/
Z3
te
• •.
•••
• ..
• •
PHONE:30C. L/ 07 C ) 3 &-)
( 6'.
PHONE:
jh 4,
Decorative Metal
All brick (simulated or regular) 114 /W41 fr')P`isr
t
Stucco Banding
A h f
0
12B
m
En
Lure of fawner Date Signature of Contractor Date
w
ny of er stucco
Accessory'Buildings
Other :.r i3c)('
i /
WHEN PAINTING IS FINISHED,
CALL FOR FINAL INSPECTION
4/23/01
. gn
* ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** : * * * * * * * * * * * * * * * * * * * * * * * * * * * **
HC -80
HC -79
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate -- r
and that all work will be done in compliance with all applicable laws regulating ,
construction and zoning. I authorize the above -named contractor, if applicable, to J=
o the work stated. Furthermore , the paint colors will be as per the attached
sample
m
PROPERTY OWNER
Name - / )e,
Address
c l3
Home Telephone 3 7 .. c - 7 . . (> J cQ
` �
Business Telephone.33 C
/ Q 7 c t, D
Fax
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'I Attachment
Other
Add'1 Detachment
Other
INSTRUCTIONS - The following steps must be taken to obtain permit from the Miami Shores Village:
Step 1. Complete the attached permit application Which be signsd by the prapeTty owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate pigcezvng c ' y$ur application. ft :roofing work will be done, a roofing application must be submit-
•
ted along with this permit application. .. • . • • . • • • • • . . • v • • • • • •
Step 2. Submit the com plete d a with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
Job Address: 1 % P ko c13,5
PERMIT TYPE (✓) I
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
Address Apt.
Folio Number Description of Work
Lot Block
Subdivision PB PG Zoning Linear Feet
Current Use of Property Square Feet Units Floors
Proposed Use of Property Value of Work /' Bldg Value
Tenant Information
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
• • • • •
• • • • ••• • • •
• • • • • • • •
• • ••• • • • • • ••
• • . MasterXermit No. 1(i.3 �` -- 5 , 4
• •• • •
.•. . . ; S u p s : d i ar y Permit No.
• • • • • • • • •
• .•. • • •
Sholvi
City
Tax Assessed /Appraised Value
Flood Zone Base Floor Elev.
ENGINEER
Name
license No.
Address
'telephone
Fax
CONTRACTOR
Name
License No.
Address
Telephone
Fax
Qualifier Name
State
PERMIT APPLICATION
73 3) 3 ) )
Zip
Page 2
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PERMIT APPLICATION
IMPORTANT NOTICES
DO NOT BEGIN ANY WORK WITHOUT HAVING RECE IVED:Y&R VILIbATED PEI I1T AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: • Mon ri d19through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED I N A CLEAN, l SgNLi'i1RY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM BIR:f /11I31 DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGE) BY EQ4JIPM Ni OR' E1$ICUS, AND MAY NOT BE USED FOR STORAGE. A bond is •
• required for work in or near the street/sidewalk. • • • ••• • • • • • • • •
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
1.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, certify that all
work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
are required for ELECTRICAL, PLUMBING, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1" Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STATE OF FLORIDA, CO
rgn.ture or uwner
�I P1/47
Y OF MIAMI -DADE
P rint Name
worn to and subscribed before me this /0 day of
SEAL:
Signature ofiNlftSrgPublic - Stat
p C. Jbti > , RY SEAL
6� GLi ".:'
T » co?i,: NUMBER
Q 1p:;1094
y,,,, ci� MY ^ :::1:.• SICN EXPIRES
F OF FAO ■A:"-1 1.2.008
STATE OF FLORIDA, COUNTY OF MIAMI -DADE
Signature of Contractor / Qualifier
Print Name
Sworn to and subscribed before me this day of
Signature of Notary Public - State of Florida
SEAL:
Personally known OR, Produced Identificatiori/ L/ 1+ Personally known OR, Produced Identification
Type of Identification Produced: L Y77 7D ;40 Type of Identification Produced:
ELECTRICAL
TYPE
Minimum Fee
QTY.
TYPE.
Dryer • • • • • • • _
`1'I 'Y.'
► • •
r
TYPE
■ ► Outlet,_ Appliance
QTY.
TYPE
Service Repair
Q'I V.
A/C Central 1 -3 Ton
Dryer Vents, Number of
Fan
Ventilation, Cost
Outlet, Wall
Ductwork, Cost of
Service, Temporary
Periodic Inspections
A/C Central 4 -7 Ton
Fire Sprinkler System
Fire Pump
Outlet, Switch
Fireplaces, Number of
Signs
A/C Central 8 -15 Ton
Fixture - Fluorescent
Oven
Space Heater (kw)
A/C Central 16-20 Ton
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugnold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Heater New
MECHANICAL
TYPE QTY.
Minimum Fee
TYPE QTY.
Condensate Drain
TYPE
Generator
QTY. TYPE Q F\.
Refrigeration, Tons
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wall/Win. Tons
Dryer Vents, Number of
Painl Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
Process/Pressure Piping
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
PLUMBING
TYPE
A/C Condensate
QTY.
TYPE
Drains, Roof
QTY.
TYPE.
Miscellaneous Fixture
QTY.
'I'YI'P.
Soakage Pit
QTY.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
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• • •
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type bf 3vork Ieittg Ilerfctrn3e4 alid quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
Page 4
OFFICE USE ONLY
CHECKLIST
❑ OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT'
APPROVAL (Commercial /
multi - family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
••• •
• • •
• • • •••
❑ PROOF OF OWNERSHIP
(Attach)
❑ IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
PERMIT FEES
$3.00 per page (Scanning Fee)
Miami Shores Village $ 0
Bond $
Metropolitan Dade County (C.C.F.) $ - K7 O (sq.ft. = x/1000
x ¢.60)
Inspector State Educational Fund $ (¢.005 / sq.ft.)
State DCA (Radon) $ (0.01 /sq.ft.)
Code Enforcement Fine $
Zoning Review
' Notary
$ 9 D
ISSUING OFFICIAL
REVIEWED AND PREPARED BY: DATE:
SECTION
Zonin:
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
D
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• • ; tlb • • •
•••• ••••••• ••
• • ••
•
•
•
•• ••• •• • • • ••
❑ CONDO ASSOCIATION APPROVAL
(Attach)
. .. . . . .
❑ HRS / DERM A�PROV LIj . • . ❑ BPR APPROVAL (Restaurants)
(Septic ?Sett?) • • • • •
PERMIT APPLICATION
❑ CONTRACTOR REGISTRATION
(On File)
TOTAL $ Cs b
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com
Is
Company
Phone #
MIAMI SNORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date /S ®,3 Time
Type Insp'n ji;iiJ /6"7
Permit No. BP D®3 °,576
Name Nie4A 6Y� Vei/j/ S- d%P,■
Address 6 f , Ale f j 574
For Inspector: 7-//? ,_® !
4
Approved
Correction
Re-Insp'n Fee
,dos 447 -o36
Name & Date
4 , a. -
MIAMI MORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204 -
Building Inspection Request
Date 7 ��`�3 Time
Type Insp'n 14 / 56,E
Permit No. B •P 0 1901' - s - e6
Approved
Correction
Re- Insp'n Fee
Name N j jn . t_1
Address f Al S
Company I /Z.4Yr,
Phone # 47 "O3
For Inspector: 2_ A ° e
Name & Date