321 NE 100 St (4)BUILDING
PERMIT APPLICATION
FBC 2004
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: ['Addition ['Alteration
Describe Work:
Submittal Fee $
Notary $
Scanning $ Radon $
Structural Review. $
Permit Fee $
Training/Education Fee $
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit No. Y l 341
Permit Type (circle): s uilding Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Ti 1/ h
tlehol . = , 1 �/ e- Phone #
Owner's Address 2/ Ci /v � t f
M r J L State Zip 3
City p 3 V
*********************w******
Tenant/Lessee Name Phone #
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company Name CO [ b Phone #
Contractor's Address
City State Zip
Qualifier Name
State Certificate or Registration No. Certificate of Competency No.
ew
Square / Linear Footage Of Work:
* * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
DPBR $
CCF $
Bond $ Code Enforcement $ Double Fee $
Master Permit No.
Phone #
Phone #
Total Fee Now Due $
/
❑ Repair/Replace ❑ Demolition
CO /CC
Technology Fee $
Zoning $
See Reverse side —>
Bonding Company's Name (if applicable)
Bonding Company's Address
City
Mortgage Lender's Name
Mortgage Lender's Address
City
Application is hereby made
commenced prior to the i5
construction in this jurisdici
WELLS, POOLS, FURNA(
OWNER'S AFFIDAVIT:
applicable laws regulating c
"WARNING TO OWNED
PAYING TWICE FOR
CONSULT WITH YC
COMMENCEMENT."
Signature
(Revised 02/08/06)
I e
APPLICATION APPROVED BY:
State
•
Owner or Agent
The foregoing instrument was acknowledged before me this
day of ,20,by
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
(-)9R
Zip
a compliance with all
ESULT IN YOUR
IN FINANCING,
_ _ ___ NOTICE OF
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
Contractor
The foregoing instrument was acknowledged before me this
day of ,20_,by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
or installation has
all laws regulating
,UMBING, SIGNS,
Sign:
Print:
My Commission Expires:
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
Engineer
Zoning