390 NE 98 St (2)MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the build-
ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami
Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kept at building during progress of the work.
Owner's Name and Address 4 c • '1
Registered Architect and /or Engineer
Name and address of licensed contractor
Location and legal description of lot to be built on
Lot Block Subdivision
Street and Number where work is to be done
State work to be done and purpose of building (by floors)
New Building
To be constructed of
Estimated Total cost of improvements $
STATE OF FLORIDA,
COUNTY OF DADE.
Remodeling Addition. Repairs No. of Stories
T) I tin/7 f- / 1 P ✓
Kind of foundation Roof Covering
Amount of Permit $
Zone cubage required plan Cubage
Distance to next nearest building Size of Building Lot
Maximum live load to be borne by each floor
I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
! -9.
be sent to
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the provisions thereof, and will require smiilar compliance from all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such s contractors, on work to be performed under this
permit, as are licensed by Miami Shores Village. 4 . r �
Remarks ( Signed) • " "
ss.
Disapproved Date
(Signed)
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Notary Public, State of Florida
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and for no other purpose.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
• to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
/—
Permit No Date Read, Sworn to and Subscribed before me.
Building Inspector My Commission Expires
PLANNING BOARD DATE
Chairman Member
Member Member
Member ... Member
Council Approved Date Disapproved Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from
the Planning Board.
A re- inspection fee of $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
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Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING Permit No. 6 P
PERMIT APPLICATION Master Permit No.
FBC 2001
Permit Type (circle): Building Electrical Plumbing Mechanical
Owner's Name (Fee Simple Titleholder) Phone #
Owner's Address
City State Zip
Tenamt/Lessee Name Phone #
Job Address (where the work is being done) .
City Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name Phone #
Contractor's Address
City State Zip
Qualifier
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit Square Footage Of Work:
Type of Work: ['Addition ['Alteration ❑New ❑ Repair/Replace ❑ Demolition
• Describe Work:
(Continued on opposite side)
*************4**!*** #r
Total Fee Now Due $
' F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ ) ,) ® 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 Cornpany's Address
City State Zip
1 .9rtgagt Lender's Name (if applicable)
Mortgage , .ender's Address
Cit)i State Zip
t
Ap` 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
instruction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
'`i'ELLS, 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,
C ONSULT 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 Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 _ , by , 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 PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print:
My Commission Expires: My Commission Expires:
********* k******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
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APPLICATION APPROVED BY:
Chc 12/15/03
Jk r,.> 10" Plans Examiner
Engineer
Zoning