PL-03-194Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
BUILDING Permit No. 3 - q
PERMIT APPLICATION Master Permit No.
FBC 2001
Permit Type (circle): Building Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Titleholder) /��� Phone # 3 0 ® 7 2 5 ®C 4 &
Owner's Address / 700 NI C (05 j
City f1 � 1 Siivf 0 State f L Zip 2,? / 3r - 2
Tenant/Lessee Name . Phone #
Job Address (where the work is being done) 1 J ] 0 - /0 ` — , jJ/u� # 3' f
City Miami Shores Village County Miami -Dade Zip ,) / - 2 14 /
Is Building Historically Designated YES NO
Contractor's Company Name 1\41
I1 fl
Contractor's Address ( t / Ai . \4t 118
City M t ce.--- State f L
Qualifier
Phone #205 - 8/ -000q
Zip f
Architect/Engineer's Name (if applicable) .Phone #
Architect/Engineer's Address
City State Zip
$ Value of Work For this Permit � & 00 Square Footage Of Work: 6 c 1
Number of: Bays Stories Families / Bedrooms / Baths
Type of Work: ['Addition ['Alteration ❑New �Repair/Replace ❑ Demolition
Describe Work: ' / / / e [.ai', L . k � � T e l 3, � g f f F n u . 4 7 - e , - - Al -s -,- e , ''
A 6C 4,r5
** ***** * * ** *** **** **** Fees, , , , *, ** ** *** * *** * ** * *** * **
County Escrow Fee $ ! , 'V Permit Fee $ / ' 1 Notary $
Education/Training Fee $ Tech $ Scanning $ Radon $
Code Enforcement $ Bond $ Struct. $
Minus Plans Check Fee $ Total Fee Now Due $ l Q I' d (Continued on opposite side)
dtc1 �,' 5 or VIEL di Id nil tnow_ - 00 a n Fc)I ri 0.4.0, 0Tht
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 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.
Owner or Agent
The fore g oing instrument was acknowledged before me this 2, 1
day of
who is
NOTARY YPUBLI
20 by Ni I na E ,
y known to me or who has produced
As identification and ho did take an oath.
Sign = �
Print: ' OBIN L ECKE
ARY PUBLIC - STA OF FI nRIDA
COMMISSION # 11637
My Commission Expires: EXPIRES 06/25/2007
BONDED THRU 1- 889- NOTARYI
ter, ****,ss***** *,r***** ** *** * *,s:***** *** *** ** ******** *** ** * ******** * *t****** *** * * *FMAG dBOW** * *,�**** * **
NDED THRU 1- 888- NOTARYI
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No. C i a 6 r
APPLICATION APPROVED BY:
chc7/7 /03
(o
NOTARY PUBLIC:
Print:
Signature
. '
The foregoing instrument was acknowledged before me this 2 1
Contractor
day of 20 6, by James A h il,ph l
who is erso . .yl y known to me or who has produced
as identification and who did take an oath.
ROBIN LUECKE
My Commission ExiESISSIO # DD2 FLORIDA
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Plans Examiner
Engineer
Zoning