655 NE 97 St (5)BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle):
Owner's Name (Fee Simple Titleholder)
Owner's Address
City f I. ( 7weeS State
Tenant/Lessee Name
Electrical Plumbing
1) N I S +- t,612.
(0 55 NE ctiti $'f. I� c E ►�n+a -�.1
Job Address (where the work is being done) S Pr -
City Miami Shores Village County Miami -Dade
Is Building Historically Designated YES NO
Contractor's Company Name NUT `fE DE TERM I N
Contractor's Address
City State
Q , ia lifier
GC LI 1 L( (3€ CH dsE- DV
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) 795.2204 Fax: (305) 756.8972
JtU.l
'% 53
Phone #
Zip 33135
Phone #
Phone #
Mechanical
36s
Zip 3 ' 3 8
S'quare Fo age Of Work: 63 1 0
?ci a 5o.oO ct. I5q.
RG7
Permit No. Q 210 05 -M ( 0 3
Master Permit No.
Roofing
75'.1750
Zip
PEFRIA ITT &ICT POe-IQQ
1147 •hone # 0 5 5 7 3. 36 (.Q
3S 573-80 k /Yd31
• Type of Work: liAddition [Alteration ❑New / 0 �� Repair/Replace [Demolition
Describe Work: rp. � W\ 0 Vv. C f'00� av� C) Gif t° C -C rid Ct d- -t`soi.J
a h be6ro a v' kA- kroawl a6Qvc..
�1
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ LOO Permit Fee $ CCF $
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ Bond $
Code Enforcement $ Structural Plan Review. $ 50 + 50 f 25-
M
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
Owner or Agent
The foregoing instrument was acknowledged before me this /
day of , 20 a 3, by ` J &nt rt L rte. " I f 1
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY P LIC:
• D
Print: 1 /
My Commission Expires:
APPLICATION APPROVED BY:
Chc 10/14/03
MIA l NIFTO
MY COMMISSION # CC 931703
EXPIRES: July 1 28, 22
TT E
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.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
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7 / 3 �3U4 4- ,r
Plans Examiner
Engineer
Zoning