DGT-10-216BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING ROOFING.
Owner's Name (Fee Simple Titleholder)
Owner's Address 22 6 ITVVV 73 _owe''
City / /� f t lAm, l
Ihere.s State
Tenant/Lessee Name
Email t A Vail
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
FL
0
Job Address (where the work is being done) 22 NW '13 Skeet
City Miami Shores Villa •e
FOLIO / PARCEL #
County Miami -Dade
Is Building Historically Designated YES NO ✓ .
Contractor's Company Name
Contractor's Address
O r ` '
$ 2,000
Phone # 30 S /53 3 S10
Permit No. DG-rk 0 arc
Master Permit No.
Zip 331s o
Phone #
Zip 33 /S0
Square / Linear Footage Of Work:
See Reverse side —>
FEB it 2 2010 '
BY:
Flood Zone A4
Phone #
City State Zip
Qualifier Name Phone #
State Certificate or Registration No. ertificate of Competency No.
Contact Phone E -mail
Architect/Engineer's Name (if applica e) " Phone #
Type of Work: ❑Addition ,Alteration New ❑ lace r
Re ai/Re p p ❑Demolition
!�■r�k:
C00- , CI were,i to /)1s (1 &.0 x -2C 9'9 e r
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ .0 . � Permit Fee $ CCF $ CO /CC $
Notary $ Training /Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Bond $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $
\c/
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 lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after 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..
Signature
The foregoing instrumen
day of
who is person
(Revised 07 /10 /07)(Revised 06/10/2009)
wledged before me this
to me or who has produced
As identification and who did take an oath.
Sign:
Print:
My Commission Expires:
Signature
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.
NO PUJBLIC: NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
APPROVED BY Plans Examiner Zoning
Engineer Clerk checked