DS-08-959GA sf fpt 11.
�► ,v Miami Shores Village REci "a
Building Department ma 2 8
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Owner's Name (Fee Simple Titleholder)
Owner's Address 0
[ /A re,
ty Ci �/ (J�CJie�' G State
Tenant/Lessee Name
Contractor's Company Name
Contractor's Address /
Value of Work For this Permit $ 900
Submittal Fee $ ,er
Notary $ �.UQ
Scanning $461.) Radon $
Bond S O' 1 1\/ i Code Enfo
Structural Review. $
10050 N.E.2nd Avenue, Miami Shores, Honda 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
/ +.
Job Address (where the work is being done) ! �l /t.&4J jar /1 sr
City Miami Shores Village County Miami -Dade Zip 334'
FOLIO / PARCEL #
Is Building Historically Designated YES N
City State
Qualifier Name ho, #
State Certificate or Registration No Certificate of i„ -, cy No
Architect/Engineer's Name (if applicable) Phone #
Type of Work: ❑Addition ❑Alteration
Describe Work: . e Ent eci { �
!
['New
�x�x
Permit Fee $ `2 CCF $ L "40 CO /CC
Training/Education Fee $ Q •150 Technology Fee $ ' L
JIM 19 2088
MIAMI SHORES
®RES VIj,L1
ia
Permit No. QJ O8 t5t1
Master Permit No.
Phone # �./�" ?S‘5‘430
Zip 331a
Phone #
Phone # 305- 511--K600
Square / Linear Footage Of Work: 850H- ° "
Repair/Replace ❑ Demolition
DPBR $ Zoning $
Double Fee $
Total Fee Now Due $ 142-732—
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,F- URNACES, 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 wi an`es rhated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and o n st on lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy `oft recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days a er -the building permit is issued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee 1I be 6l rged.
Signature
Signature
Contractor
e h fore oing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 1 , 20 0 I , by LO3 11441AG , day of , 20 _, by
who is rsonall known to me or who has produced 3 L .' n 1 known y p � IJ1Md who is personally ly kn wn to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
** ****************** e************* ** * **** ** * * ** **** * ** * ** * ******a *********** *** ********** ** * * ******* *e*****
APPLICATION APPROVED BY:
(Revised 07/10/07)
r'1
Owner or Agent
I(
IV
d
tit
Sign:
Print:
My Commission Expires:
Plans Examiner
Engineer
Zoning