DGT-10-09-175810050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBRR• _ 05) 762.4949
BUILDING
RECENED
PERMIT APPLICATION .'T 2 6 200
FBC 20
Permit Type: BUILDING ROOFING Z ,
Owner's Name (Fee Sim le Titleholder) C- CO r C S ! / G 13 }}-,� 10 Phone # 8‘ - 66 J - 041
Owner's Address r
City»I►`) 1 c fi 10)2 te, State FM-- Zip 33 I3 c
Tenant/Lessee Name
Ephail
tO "
Job Address (where the work is being done)
City
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company Name ( !k
Contractor's Address
City State Zip
Qualifier Name
State Certificate or Registration No.
Contact Phone
Miami Shores Village
Architect /Engineer's Name (if applicable)
Type of Work: ❑Addition
Describe Work:
Value of Work For this Permit $141(
Miami Shores Village
Building Department
❑Alteration
❑New
Phone #
Permit N o . 7 T ) O 1 1 5,
aster Permit No.
Phone #
Phone #
) Competency No.
E -mail
Zip
Flood Zone
Square / Linear Footage Of Work: 2 Lf
X
R epair /Replace CI
iM t A- L c. 47. E1
52 ***** * * * * ** * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
S bmittal Fee $ 50. Permit Fee $ CCF $ CO /CC $
Notary $5.0O Training /Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Bond $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $
See Reverse side —*
Sign:
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 N 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 Contractor
The foregoing instrument was acknowledged before me this" `he foregoing instrument was acknowledged before me this
day of 3( ? F , 204% by PO( S , O (J((J ; day of , 20 , by
�4 o is personally known to me or who has produced {L� p who is personally known to me or who has produced
t lJ�� .-- As identification and who did take an oath. as identification and who did take an oath.
Print:.
NOTARY.,PUBLIC:
APPROVED BY
Coh
< j l rn °s•h' �lrsr;0 J ' J11
My Commission Explr r�y.. A s o,. Ve7
(Revised 07 /10 /07)(Revised 06/10/2009)
Plans Examiner
Engineer
Signature
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Cp
* * * * * * * * *** * * *** *+ Fir**** F*** 2 *********** d;**; F************** k******* ** * * *:F * * * ** **** ** *de** ** * * * * *: **** *fie ** *h: **
Zoning
Clerk checked