PL05-139BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building
Owner's Name (Fee Simple Titleholder)
Owner's dress
City t
Tenant/Lessee Name
Job Address (where the work is being done)
City Miami Shores Village
Is Building Historically Designated YES
Contractor as auaress
State Certificate or Registration
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit
Type of Work:
Describe Work:
cc d
State
0.g S N
DAddit' n DAlt
Total Fee Now Due $ 564.3o
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit No. P' 1W
Electrical
.
6 Q NE
Contractor's Company Name 3 L \
1 6 S '44- ok‘
County Miami -Dade Zip 1 35 3 V
NO
o S,G 7 t 1- tl
Ph one #
�,
i'tfr Zip 330 f
Master Permit No.
Zip
Phone #
New 1W Repair,
Mechanical
Phone # 3 Or'• 3'7 S- 7017-c
Square Footage. Of Work:
4
place [ •De olition
p
* * * * * * * * * * * * * * * * * * * * * * * ** es ******************************
Roofing
Submittal Fee $ Q j Permit Fee $ 1 " CCF $ * (00 CO /CC
Notary $ Training/Education Fee $ o 2 0 Technology Fee $ 2,50
Scanning $ .00 Radon $ Zoning Bond $
Code Enforcement $ Structural Plan Review. $
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 A)i'r' IDAVIT: 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 ) days after the building permit is issued In the absence of such posted notice, the
inspection will not be approved and a rei ection fee will b arged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before a thi
day of 20 by J S cc
—whims personally known to me dr who has produced
As identificatio and who did take an oath.
N / /N / / t / / /f/
NOT.. • e : LIC: '� RHONDA P. FREDERICK N
S i
Bonded Ow (800)432-4254:
PCm
, f' _ is Roo A A Nn Assn.. Inc I
� f ' na
N /NN/ /N / / / / / //N
My Commission Expires:
APPLICATION APPROVED BY:
chc 05/13/03
Comm# D00337010
7121/2008
6
The foregoing instrument was acknowledged before me this
da z ( 20 6 by 2 =,s
who is personally known me dr who has produced
as identificat' and who did take an oath.
/ RHONDA P FREDERICK
N••/
"7 " 000337010
_ E r' 7/21/2008
,: Ann- 1 "IN (500)432 -4254
Florida Notary Assn., Inc
My Commission Expires •N
Print:
z;) A /& °,
,J .e
7 O)4 lans Examiner
Engineer
Zoning
/N