250 NE 97 St (11)BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Owner's Name (Fe Simple Titleholder)
Owner's Address �` 50 A .
City ft / ,9'/ gr // State
Tenant/Lessee Name
Job Address (where the work is being done)
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated
Value of Work For this Permit $
Submittal Fee $
Structural Review. $
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Plumbing Mechanical Roofing
6 , 4049 - //51 Phone # 34DS — � J
YES
Contractor's Company Name
Contractor's Address
City
Qualifier Name
Permit Fee $
Electrical _
County
`-5c 2 727/
NO
Miami -Dade
Type of Work: Addition nn / ['Alteration ( I)New
Describe Work: 61 L c") %��'TLN
Master Permit No.
Zip 3 3 f
Phone #
State Certificate or Registration No. Certificate of Competency No.
Square / Linear Footage Of Work:
Notary $ Training/Education Fee $
Scanning $ Radon $ DPBR $
Bond $ Code Enforcement $ Double Fee $
❑ Repair/Replace
Total Fee Now Due $
r@MEWL7--:
SEP 2006
B Y:
zip 3343f"
CCF $ CO /CC
Permit No. E i 2 �`� � V
Phone # � 6
State Zip
Phone #
Architect/Engineer's Name (if applicable) Phone #
See Reverse side -*
111 Demolition
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees ** ****** ***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Technology Fee $
Zoning $
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, ertified copy of the recorded notice of commencement must be posted at the job site
for the first insp • ion which occurs s ven ays after the building permit is issued. In the absence of such posted notice, the
inspection will 'ot .e approved and a r in . ' on fee wil�be charged.
Signa / L ;; / /(,�i Signature
Contractor
T
egoing instrument was acknowledged before me this v=z The foregoing instrument was acknowledged before me this
20O(2by Gi CC)1 C/ «,, day of , 20 , by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY P !: LIC:
Sign.
Print:
My Com ission Expires:
* * * * * * ** * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
(Revised 02/08/06)
0,; , j2
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
**************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
Engineer
Zoning
City
Miami mores V iiiage tuliaing ieparimeni
Owner's Name (Fee Simple Titlehol er) �J
GG�� n
Owner's Address 4`'5O
city r - - � city State
Tenant/Lessee Name — Phone #
Job Address (of where the work is being done) 250 N C1
City County Zip
Legal Description
Contractor's Company Name Q V-► - 0` Phone #
Contractor's Address
Qualifier
Describe Work: ILO —
I hereby certify that the work has been abandoned and /or the contractor is unable or
unwilling to complete the contract. I hold the Building Official and the Village of Miami
Shores harmless from all legal in vement.
Signature
: •�/ _ Contractor
e 'oreaoine instrument was acknowledged before me this (t) The foregoing in e . ent was acknowledged before me
is
day of fe e , NOG. by day of . 20 _ by
who is personally known to me or who has produced who is personally known to me or io has produced
As identification and who did take an oath. as identification o who did take an oath.
NOTARY
Sign:
Print:
My Com
Rev. 09/19/03)
ission Expires:
Change of Contractor
Permit No.
Signature
Phone #36s
,
Zip 33
State Zip
NOTARY PUBLIC:
Sign:
Print:
My Commission expires:
PV ,_
= . 4.,, - E xp a � es: k. , y :7
Bonded 1`hru
ios Atlantic Bonding!'0 , I„-