RF-10-1131BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING 1 E . _
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
Owner's Name (Fee Simple Titleholde
Owner's Address / /0
City I -. State
Tenant/Lessee Name
Email
ZLE
_
Master Permit No.
Permit NoR O — 1 ) V
hone# �0
Job Address (where the work is being done) /7 /'O 70 6/*-4\62:7:
City Miami Shores Villa a County Miam -Dade Zip s/�
FOLIO / PARCEL # / 8 —' O
Is Building Historically Designated YES
NO
� � C��IId��
JUN 2 Y 2010
Flood Zone
Contractor's Company Name
Contractor's Address
City
State Certificate or Registration No. CC . Y 5 7 ,9 Certificate of Competency No.
Contact Phone E - mail t hV Cfr4 I S�'4L� r I
Qualifier Name
Phone # ��` 9
Zip
Phone #
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ ROO Square / Linear Footage Of Work:
Type of Work: ['Addition ['Alteration ONew ,rERepair/Replace D Demolition
Describe Work: /Mar
Q .' 77
*** * * * * * * * * * ** * * * * * * * * * * * * * ** * ** Fees*** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ CCF $ CO /CC $
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Bond $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $
See Reverse side -+
Bonding Company's Name (if applicable)
Bonding Company's Address
City
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
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 ' mmencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building perm issued. In bsence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Owner or Agent
The fo oing instrument was ackno edged before 1 e r
I
dayofl� ,20 q It 'y IA ndr A 4 I l C. R.
who is ersonally known to me or who has produced 0L
NOT
Sign:
Print:
State Zip
My Commission Expires:
APPROVED BY
(Revised 07 /10 /07)(Revised 06/10/2009)
State Zip
ntification and who did take an oath.
NOTARY PUBLIC:
ti <N °0 ry � , � �°
r` , g• Sign:
Print:
.,:sp
f, k �� ® My Commission Expires: c K
•
Contractor
The for oing instrument was acknow le
ay of , 2010, by
who is personally known to me or who has produced
as identification and who did take an oath.
Plans Examiner t®993
Zoning
Engineer Clerk checked
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Shirley Rodriguez
173 NW 106th Street
Miami Shores. FL 33150
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