EL05-312BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building
Owner's Name (Fee Simple Titleholder)
Owner'[ Address 9q Q M,E .
City 110 11 State
Tenant/Lessee Name
Job Address (where the work is being done) %R l 1•! . , qZ
City Miami Shores Vill age County Miami -Dade
Is Building Historically Designated YES, NO �•—
Contractor's Company Name
Contractor's Address Y1 l S
City -i Avat alb tS
State
Qualifier e" \
State Certificate or Registration No.C-1
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit
Total Fee Now Due $
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305 ' .2. • _ i _ a .8972
Electrical
RE EWE
SEP12
9M
Job'
Permit No. 1OS 312_
ster Permit No. EPOS 12
Plumbing Mechanical Roofing
Phone #
Zip
Phone #
Zip
Phone # »S 6Z-4- tots-3
Certificate of Competency No. rrI S /
Phone #
Square Footage Of Work:
Type of Work: Addition ❑Alteration ❑New ❑ Repair/Replace demolition
Describe Work: c111 le c )Q 1 ,
e
/* **************************Fees******************************
Submittal Fee $ t/% Permit Fee $ /6 r ao G CCF $ CO /CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ Zoning Bond $
Code Enforcement $ Structural Plan Review. $
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 ANFIl)AVIT: 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of tfi rergorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the bui 41 an$ por i ''s .issued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charge 4 '
As identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUB
Sign: Sign:
Print: Print:
************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
chc 05/13/03
Signatur Signature
Owner or Agent
The foregoing instrument was acknowledged before me this The foregoing instrument was 5 before me t
day of ,20 ,by dayo 200S
who is personally known to me or who has produced who is person lly kn . • . . ' . e or who has produced
Contracto
My Commission Expires: My Co ssion Exprs
cation and who did take an oath.
********************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY: <// /� = = � Z S� - S Plans Examiner
Engineer
Zoning