Dock-07-470.411401 a
hMA [',s bus( *
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING Permit No. Vek .4
PERMIT APPLICATION (351°4°-/- Master Permit No.
FBC 2004 Oct
Cit N` . 5h °A
Tenant/Lessee Name
Contractor's Company Name
Contractor's Address
Value of Work For this Permit $
Type of Work: ['Addition
Permit Type (circle): Building
Owner's Name (Fee Simple Titleholder)
Owner's Address I Z?
State
Miami Shores Village
Building Department
Electrical
// e
Job Address (where the work is being done 9c? N `C 104 S- y aV
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated YES
['Alteration
B4O
County Miami -Dade Zip 3
NO L/
Zip ( 3
Phone #
Plumbing Mechanical Roofing
tO 5 E" l Phone #
City N) . \ GSA&
Qualifier Name
State Certificate or Registration No. G G ( 15 6 3
Architect/Engineer's Name (if applicable) G . , ()Lek) 5.
Square / Linear Footage Of Work: e 3
❑New
Repair/Replace
❑ Demolition
Permit Fee $
0
CCF $ Co CO CO /CC
cTO� 1
E
MAR 0 9 2007
B Y: _ r e_____
Submittal Fee $ _
Notary $ 5 Training/Education Fee $ 3. -3 Technology Fee $ ' I' "Tai
Scanning $ Radon $ DPBR $ Zoning $
Bond $ / Code Enforcement $ Double Fee $
Structural Review. $ 66/ eV Total Fee Now Due $ a ` • 41)
See Reverse side —+
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender; s Name (if applicable)
Mortgage L'ender'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 At HDAVIT: 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
The foregoing instrument was • : owledged before me th foregoing instrument w ackno :'ledged before me this Q
day of /(QYth , 20 d , by Lpa is 3“1 , day of hi/C4 20 , , C�sl d/ 7i deii ,
who i ersonally kno . to me or who has produced' who is
As identification and who did take an oath.
NOTARY PUBLIC:
MON CALISSE"THOIA
MY COMMISSION s D 8 9 • �timu u ' Notary . o 1 -
Sign:
Print:
My Commission Expires:
/(
Owner ors t
APPLICATION APPROVED BY:
(Revised 02/08/06)
Engineer
3e 07'
(c e C-v), J. A.
"i-us 4,1&,
D O iY5—e 73
Signa
NOTARY PUBLIC:
Sign:
Print:
to me or who has produced
as identification and who did take an oath.
My Commission Expire
S rze ", Plans Examiner
Zoning
cv° II LY