BP-04-698RECEPVED
MAY 2 ' 2004
BUItAllN
PERMIT APPLICATION
FBC 2001
Permit Type (circle ' Build; / g Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Titleholder) , L ,/
'Owner's A dress. /r) 416 /
(-GC tokt S)i tte P
Tenant/Lessee Name
Job Address (where the work is being done) )'/)-- ,(/ 7 / _CE
City Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name
17 w t
Contractor's Address
City State Zip
Qualifier —� hki
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit Vt3 0 0
Type of Work• dition ❑Alteration
DescribeWor a //7 1/7c/ O f
Total Fee Now Due $ 7° 3 ° argL
(Continued on opposite side)
Miami Shores Village e
Building Department /-F/7 3 76 7' g g7
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
/)
❑N�
Permit No. P 9
Master Permit No.
Phone #
Phone #
Square Footage
❑ Repair/Replace.
* ** * * ** * * * * * * * * *** * * * * * * * ** F ees * * * ** * * * * * ** * * * * * ** * * *** ** * * **
❑ Demolition
Submittal Fee $ Permit Fee $ 6 0, ° ° CCF $ , C 0 CO /CC
Notary $ 57, O 0 Training/Education Fee $ b Technology Fee $ 1 t C 0
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 d value exceeding $2500, the applicant must
esiiln i e
promise in good faith that a copy o the notice o commencement and construe ooh, 'law brochure will be delivered to the
P S .f � PY .f f � person
P
whose property is subject to attachment Also, a certified copy :of the recorded tic' of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building pei4)it 'ssued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged \ \\
Signature p
My Commission Expires:
APPLICATION APPROVED BY:
Chc 12/15/03
Owner or Agent ;,,> Contractor
Thegoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
204, s y `.! ► / : = day of , 20 , by
who is personally known to me or who has produced ij L who is personally known to me or who has produced
S o.1 As identification and who did take an oath. as identification and who did take an oath.
NO UBLIC:
1rrdiGsi :n D »
14 �oc� VL ° C ✓CTPCF'3 a 2COG
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
************************************************ %� ie *S*0* *********** * * * * * * * * * *,><*,x*** * * * * * * * * ***
zW/6 5
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Plans Examiner
Engineer
Zoning
Miami Shores Village
Paint Color Approval and Agreement
Date j O
Owner's Name oisd-at Jackavt
Owner's Address (a N E (JO/ 4,
City (atom, State V
Job Address (where the work is being done)
City Ivfiami Shores Village County Miami-Dade Zip
Is Building Historically Designated YES NO .
Contractor's Company Name (if applicable)
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
All elements on the site must be listed and indicate the color to be painted
Walls Ut `Wlt.
Fascia LA p %k
Drip Cap /drip Edge 1\) 1 )1"
Soffit
Roof wa,o-e.
Flower bins /
Shutters
Awnings yu Q
Chimney
Doors and door jams
Garage doors
Railings
Fences
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
applicable laws regulating construction and zoning.
Signature � ` td
APPLICATION APPROVED BY:
Owner or Agent
aritsL
P& Z Official
» / I
Zip
Phone #
Date
Phone #
Date