1048 NE 99 St•
RECCEJ %I7
SEP ` 5 003
BUILDING
PERMIT APPLICATION
FBC 2001
Miami Shores Village
Building Department
he tou, .
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Permit No. P 2-003 - 1i
Master Permit No.
Permit Type (circle): : uildin: Electrical Plumbing Mechanical Roofing
0 Owner's Name (Fee Simple Titleholder) 'DA,,.I lC�L, Tp, 4,46/L Phone # (c5) -S 1 -(
Owner's Address 1 1.1.i✓ 10-62.1> yi/L eel—
Cit M i Prr-i t S Hill C—S State Pt ofU DA Zip ?•3l 3
Tenant/Lessee Name Phone #
• Job Address (where the work is being done) 10 E Ofih VI T34 STZGGT
City Miami Shores Village County Miami - Dade Zip 3'31
Is Building Historically Designated YES NO X
Contractor's Company Name Phone #
Contractor's Address
City State Zip
Qualifier
Architect/Engineer's Name (if applicable) - Phone #
Architect/Engineer's Address
City State Zip
• $ Value of Work For this Permit 4 000
Minus Plans Check Fee $ Total Fee Now Due $
Square Footage Of Work:
F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
4(00 eoa.gr.
Number of: Bays I Stories ( • Families 1 Bedrooms Z Baths Z
Type of Work: ❑Addition ['Alteration ['New ❑ Repair/Replace ® Demolition
• Describe Work: tOPt 1 out-21 -4i-L& A. e.6.42.6.6 ,e Copkv.S 1O,.4 It) L V tr.LE7 ‘-PAhre..
i W 1Lt_ tbg- ¢.crtOX11► -LEi w'TFiLLoJL wed 14 wiktc. 44,.kvG 6ai--1
____ )' 1 Nl TIkP C-, Ate r AJLCsd. to4.6 R dv-1 t rAb The J
-
County Escrow Fee $ Permit Fee $ Notary $ 5 -cXD .
Education/Training Fee $ Tech $ Scanning $ Radon $
Code Enforcement $ Bond $ Struct. $
(Continued on opposite side)
i� kick 3O.0) KGsr) .
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 achment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first i rs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection r not be a • roved and reinspection fee will be charged.
day of 202 , b TQnner
who is personally known to me or who has produced DI i ll21
As identification and who did take an oath.
Signature
wner or Agent Contractor
The foregoing instrument was acknowledged before me this l 5 , 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.
NOTAR UBLIC: _ NOTARY PUBLIC:
Sign: ¥()t 1U
Print: ,, Mabel Vargas Sign:
• a �% cnmmiccinn #DD231984' Print:
My Commission • Expires: Jul 13, 2007
... • Bonded Thru My Commission Expires:
**4W4 * *iF,/ 1FCAStx94wllMrlt SF',k '+HFr►i *** * * * ** ** trek ** ** *** *lr*** * * *** *Art * * ** **** ** ********
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
APPLICATION APPROVED BY: Plans Examiner
Engineer
Zoning
Chc7/7 /o3
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