DS-09-340C'1
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BUILDING
PERMIT APPLICATIO
FBC 20
Permit Type (circle): Building Roofing
Owner's Name (Fee Simple Titleholder) _% "/ '
Owner's Address � L y f 7 S r
City / A- P i S /c SState �C
Is Building Historically Designated YES
Contractor's Company Name
Contractor's Address
Architect/Engineer's Name (if applicable)
Miami Shores Village
Bu ldin De a t e t
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax; (305) 7561(972
$ECE ED
MA 0 5 2489
NO V
Permit No, D3 U q
Master Permit No,
Phone #
Zip 3 3
44.
7 7d
Tenant/Lessee Name / Phone # . -'
Email J 0 bv) L j-Z;r..e=S 6 - , - , jc -/-0 - ? , /.- C ,3
Job Address (where the work is being done) ltrAfi AS Cl bVt
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL #
Flood Zone
Phone #
City State �i
Qualifier Name Pho
State Certificate or Registration No. Certificate of Competency No.
Contact Phone E -mail
Phone #
Value of Work For this Permit $ / 0 C.: C ` ° .C:=`
Square / Linear Footage Of Work:
Type of Work: [Addition nAlteration New C Li Re air, 'Re lace
f p' p Demolition
Describe Work: _ VA z> •'l Cq -
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Submittal Fee $ t_ Permit Fee $ CCF $ CO /CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ . DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $ .
See Reverse side -
cl
e Fees
Bonding Company's Name (if applicable)
Bonding Company's Address
City tat:) ,ip
Mortgage Lender's Name (ii 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.
NOTARY PUIuL `
Sign:
Print:
iViy Commission Expire
(Revised 07/10/07)
Signature �
1
f Owner or Agent Contractor
The fore oing instrument was acknowledged before me this 5 The foregoing instrument was acknowledged before me this
day of 10 , 20 e t , by 0141 LawrotC((' fiflot,5 , day of , 20 , by
who is perso known to me or who has produced f 'waS who is personally known to me or who has produced
L Ail gg 0 As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
******** *** ***** * * ***** * * **** ** * * * * * * * ********** ** * * * * **** * * * * * * ** ** * * **** * **
APPLICATION APPROVED BY Plans Examiner
Sign:
Print:
My Commission Expires:
Zoning
Engineer Clerk checked