PT-7-365BUILDING
PERMIT APPLICATIO
FBC 2004
Permit Type (circle):
Job Address (where the work is being done)
Contractor's Company Name
Contractor's Address
State Certificate or Registration No.
Building
Value of Work For this Permit $ ��V
Type of Work: ❑Addition ❑Alteration
Describe Work: Cie sa-
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
FEB 2 6 2007 Master Permit No.
MCIEEV'M Permit No.
BY: ,
Electrical Plumbing
Owner's Name (Fee Simple`' - er F D Lt./CftPhone # DDT /21 2 -/v 3
Owner's Address 1 V! S f 1' G / S r r/
City .414 ' 6� , • State Ft Zip l J d
Tenant/Lessee Name Phone #
City Miami Shores Villa e Co#tt4 / Miami -Dade Zip
FOLIO / PARCEL # l T - 22-3 2 - --- .
O 3 ` pi 2-
Is Building Historically Designated YES
City Stated i
Qualifier Name
Architect/Engineer's Name (if applicable) Phone #
***************************************F ************* ** * * * * * * * ***** * ** ** ** * * * * * ** * **
ew•
Phone #
Mechanical Roofing
Certificate of Competency No.
Square / Linear Footage Of Work:
❑ Repair/Replace ❑ Demolition
CCF $ CO /CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverse 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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDmONERS, ETC
OWNER'S ANTIDAVIT: 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 FAIL RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT." ///,-
Notice to Applicant: As a condition to the issuance of a u ing permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commenc t ane4 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 • tion which occurs seven (7) days after the builrjtng ermit is issued. In the absence of such posted notice, the
d." inspectio ilk : t be approved and a reinspection fee will be charge
✓
Sign•ture " %' Signa e,
NOTARY PUBLIC:
Sign: Print:
My Commission Expires:
APPLICATION APPROVED BY:
(Revised 02/08/06)
Owner or Agent pp,�,,--
The foregoing instrument was acknowledged before me this ✓-h The foregoing instrument was acknowledged before me this
day of 1�i� ,20 L1tote , day of ,20 , by
w sonally known to me or who has produced f7. Ma /Lwho is personally known to me or who has produced
b
As identification and who did take an oath. as identification and who did take an oath.
"1 ci;'' % MONICA LISSETH DIAZ
MY COMMISSION # DD 483995
eondeehrurooteryaubi 2 Trttere Si
t:
NOTARY PUBLIC:
My Commission Expires:
o7
(e (o
Contractor •
Plans Examiner
Engineer
Zoning
Date: - 0
Owner's Name: R)/0 / 6 9 4 AfL()cP Phone #: ' )f 2 2/13
Job Address (where the work is being done): /..-77S AL /Oct £'T
City: Miami Shores Village County: Miami -Dade Zip: /-3
Is Building Historically Designated ?:
Contractor's Company Name (if applicable):
Walls:
Shutters:
Awnings:
Chimney:
Decorative Metal:
Sign
Miami Shores Village
Paint Color Approval and Agreement
All elements on the site must be listed
Fascia: 0
Drip Cap/Drip Edge: /4/1
Soffit: /-
,, f
Roof: C f e.- — `f 4 iii/
Flower Bins: A '
4/ A
/110
Doors and Door Jams: 1/ /4
Garage Doors: J t1/4
Railings: ./(J/4
Fences: ✓ V W)
/
All brick (simulated or regular): /1/
Stucco Banding: ��'d
Any other Stucco Features:
Accessory Buildings:
Other:
APPLICATION APPROVED BY:
P & Z'OFFICIAL
YES NO ?
Phone #:
and indicate the color to be printed
Attach color Samples
with numbers
white
El
INT. RM
OWNER'S . i 1► VIT: I certify that all the foregoing information is accurate and that all work will be
done in . mplian • with all applicable laws regulating construction and zoning.
—0 7
crr
Date:
* *MUST BE ATTACHED WITH PURPLE BUILDING APPLICATION * *