DS-10-504BUILDING
PERMIT APPLICATION
FBC 20
Owner's Name (Fee Simple Titleholder)
Owner's Address
City
Tenant/Lessee Name
Email
Value of Work For this Permit $
Type of Work: ❑Addition DAlteration
P R) W Ve
Describe Work:
Submittal Fee Permit Fee $
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
State Certificate or Registration No. t 5V27f t
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL #
Is Building Historically Designated YES
Contractor's Company Name s&Wj ,*e, ciA) .y 166 Phone # — S93/
Contractor's Address f ➢ a) s 33 .r
City "L6 State r Zip
Qualifier Name /* /�� \.7 — re5 - Phone #
Contact Phone d f' 3� • 573/ E -mail ,e61 -.77 fTc) & 406 r.
Architect/Engineer's Name (if applicable) Phone #
* ** *F * * * * * * * **
0 4 0
Notary $ Training/Education Fee $
Scanning - 00 Radon $
Double Fee $
Structural Review. $ Total Fee Now Due $ t (pg'94
Violation date:
NO
Square / Linear Footage Of Work:
❑New
DPBR $
P N -504
Master Permit No.
Phone #
1p)30MBVIIIII
MAW 2 5 2010
BY:
Flood Zone
Certificate of Competency No.
S® 0
❑ Repair/Replace ❑ Demolition
3 tka J
^3 JPA R
ybb 043 64 5 t 4ilt
�k 9
CCF $
Technology Fee $ 1. 0()
Bond $
See Reverse side -*
�G.
Bonding Company's Name (if applicable)
Bonding Company's Address V f�
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 WO RK , P LUMBING, 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 reinspection fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this j L-
day of jL (tli \ , 20 )(r , by q i i E_ '( 0-1
who ' ersonalLy know_tp me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commis
APPROVED
MAYDA L. PEREZ
%, Notary Public • State of Florida
•z My Comm. Expires Nov 19.2012
7 Commission rY 00 839988
BY �� 4./ l/C/ Plans Examiner
(Revised 07 /10 /07)(Revised 06/10/2009)
Engineer
Signature !f I
Contractor
The foregoing instrument was acknowledged before me this
day of , , 20 /0, by 4/ .C-
who personally kno , o me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
" "' • A L. PEREZ
4 �„ F n 0 X
oTar ublic - State of Florida
• My Comm. Expires Nov 19, 2012
i ▪ Commission d} 00 839988
Clerk checked
Zoning
Inspection Number: INSP - 138981
Scheduled Inspection Date: October 13, 2010
Inspector: Bruhn, Norman
Owner: MAYER, SIMONE
Job Address: 620 NE 101 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: KEITH JOHNSTON CONSTRUCTION
Building Department Comments
driveway on the back of the house
Passed
Failed
Correction
Needed
Re- Inspection
Fee
October 12, 2010
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspector Comments
For Inspections please call: (305)762 -4949
Permit Number: DS -3 -10 -504
Permit Type: Driveways /Sidewalks /Slabs
Inspection Type: Final
Work Classification: New
Phone Number
Parcel Number 1132060172130
Phone: (305)370 -5731
Page 3 of 23
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