BP-04-288BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building Electrical
Is Building Historically Designated YES
Contractor's Company Name
$ Value of Work For this Permit ,pU
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fay_ (3# - 56.8972
n �� „
fry % is L A
Plumbing
Owner's Name (Fee Simple Titleholder) C ! J� = Phi Phone # ® ' � `7 —) 0 3
Owner's Address 961 N F 99 ,,
City TV) i. cal tvt 56-101 State - Zip 73
Tenant/Lessee Name Phone #
Job Address (where the work is being done) 95 h t 6/42
City Miami Shores Village County Miami -Dade Zip
NO
Permit No. be it1 _ 2253'
aster Permit No.
Phone #
Mechanical Roofing
Contractor's Address►, //
City State �'
Qualifier
Architect/Engineer's Name (if applicable) Phone #
Type of Work: ❑ nion ❑Alteration ❑New ❑ Repair/Replace - ❑ Demolition
Describe Work: IF G eo
Total Fee Now Due $ CC/4 C b aq 3 $ (
Square Footage Of Work:
Submittal Fee $ /, ' Permit Fee $ .00 CCF $ f t0 0 • CO /CC
Notary $ 5.0 0 Training/Education Fee $ ' d-[) Technology Fee $ ( -‘50 •
Scanning $ Radon $ Zoning Bond $
Code Enforcement $ Structural Plan Review. $
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 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 reinspectio� fee will be charged.
S
Owner o Agent 2 Contractor
The foregoing instrument was ac owledged before me this 3 The foregoing instrument was acknowledged before me this
day of y�i� 20 V "� by V061 'i it filo le , day of , 20 by
who is personally known to me or who has produced T1A,Q 1 d . who is personally known to me or who has produced
( 36C0 6 4 {0 1 q(s identification and who did take an oath. as identification and who did take an oath.
NOTARY 'UBLIC:
Sign: A. i1 /' ∎ ∎111■■
awmpap
Print: thI l J 1bI
My Commission Expires:
Expires: Jul 13, 2007
Bonded Thru
(Certificate of Competency Holder)
State Certificate or Regisliation No. Certificate of Competency No.
**** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
Cho 12/15/03
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
3 75-Ay
Signature
* * ** *Ted* gl *yer * * * * * * * * * * * * **
Plans Examiner
Engineer
Zoning
Date -
Owner's Name 1.,z 3.. A 0.(/'
Owner's Address '15 '
City pm; 5° State d Zip
Job Address (where the work is being done)
Q5 �Lr �q � `l -
City Miami Shores Village County Miami-Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name (if applicable) Phone #
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All elements on the site must be listed and indicate the color to be painted
Walls
Fascia
Drip Cap /drip Edge
Soffit
Roof
Flower bins
Shutters
Awnings
Chimney
Doors and door jams
Garage doors
Railings
Fences
applicable 1 regulatinn construction and zo
Miami Shores Village
Faint Color Approval and Agreement
APPLICATION APPROVED BY:
Owner or Agent
Decorative metal
All brick (simulated or regular)
Stucco banding
Any other stucco features
Accessory Buildings
Other
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
Phone # 5
Attach Color Samples
With Numbers
Date 3—
Date Vil
chc 6/18/03