DEMO-08-631BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Roofing
Owner's Name (Fee Simple Titleholder) Phone #
Owner's Address 156eirN t Q
City t 1t/' 44-104 State
FOLIO / PARCEL # \ i • <7.
Is Building Historically Designated YES
Value of Work For this Permit $ 1 ocke::.
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
09m10 ) 1 45
Zip r3
Job Address (where the work is being done) ■+ " %
(P ' o\k '2 Z�
NO
S
A-WS --
Permit No. 05 ‘40 0
J
Master Permit No.
Tenant/Lessee Name Phone #
City Miami Shores Village County Miami -Dade Zip
Contractor's Company Name &t c ti, • .1 Phone #
Contractor's Address /X> ( 2 C
City '✓'��- State
Zip • 3 ""S
ty p z4-
Qualifier Name �► y''� � C . 4 rut_ Phone # 3 ' Z7 ' P.0-0
State Certificate or Registration No. ( A L p Si lea- Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
Square / Linear Footage Of Work:
Type of Work: ['Addition ❑Alteration ❑New ❑ Repair/Replace P emolition
Describe Work:
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ / S?U ° • CCF $ O .(QO �C /CC
Notary $ ' � • Training/Education Fee $ 0 - 00 Technology Fee $ • N
Scanning $ i / 1 Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ AR S Noe Total Fee Now Due $ 1 (0 Z " LA J
See Reverse side -)
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 F.I.F.CTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDMONERS, 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
The foregoing instrument was acknowledged before me this The foregoi
day
who is personally known to me or who has produced who i personal
As identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign:
Print: Print:
My Commission Expires:
APPLICATION APPROVED BY:
(Revised 07/10/07)
Signature Signature
Owner or Agent Contractor i,l
_ strument was acknowledged before me this 1V
day of , 20 _ , by , by ✓A ..u' i 1. t,
NOTARY PUBLIC:
My Commission Expires:
‘,///A g •
4
y known to me or who has produc
I s identification and who
4 ,44 e g,
epo
Lot
Plans Examiner
Engineer
Zoning