BP-04-40ECEHVED
IA 3 2004 N.E.2nd Avenue, Miami Shores, Florida 33138 �r
Tel: (305) 795.2204 Fax: (305) 756.8972 ® ®®
BUILDING Permit No. BP-Mg
PERMIT APPLICATION Master Permit No.
FBC 2001
Permit Type (circle). Building Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Titleholder) "l( 6 12, ri Phone # `:O S -
Owner's Address
City . r a: ( � d State Zip 1
Tenant/Lessee Name Phone #
Job, Address (where the work is being done)
City Miami Shores Village
Is Building Historically Designated YES NO
Contractor's Company Name
City State
Submittal Fee $ 53 , 0) , Permit Fee S
Notary O d Training/Education Fee $
Scanning $ Radon $
1V11c1II11 3iiore5 V iintge
Building Department
County Nfiami -Dade
Phone #
Zip
Contractor's Address
Qualifier
Architect/Engineer's Name (if applicable) Phon
$ Value of Work For this Permit - • 0,06 Square Footage Of Work:
Type of Work: ['Addition [' ❑ Alteration ❑New l ❑ Repair/Replace Demolition
Describe Work: 3 tab i yon} awn kt t. / )7 c l 9UQ is
o r n C a i61 Y ` X C Y_ eizieN ( f i e n # i d e i h i i b rfrr f )-e
'.1.l4 c rintiQx SIC1Q door s
/p0 __
0 aO
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
CCFS Or 6 0
Technology Fee $
Bond $
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $ a 3 D
(Continued on opposite 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 FT.F,CTRICAL 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 n ticeof commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment A �'o„a copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) ys after the building permit is issued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee ll be c
Signature
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:
*** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
Chc 10/14/03
-'' ,� 1' /Signature
Thefo g o g instrument was acknowledged before me this
� t
day of ' _% , 20 , by
Contractor
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:
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
******* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
JAN 1 4 20% Plans Examiner
Engineer
/ /y /0") Zoning