PT-06-2919BUILDING
PERMIT APPLICATION -
FBC 2004 - B
Permit Type (circle):
Owner's Name (Fee Simple Titleholder) Iey), CAie1l e 1 ► l b li ft Phone # 305 P) [g 1 �b l
Owner's Address OW NW l i t 7 ?( G. r
City A ! U-U (N. State Ct. Zip 3c3` / D1 ,
Tenant/Lessee Name
Building
Job Address (where the work is being done) p
City Miami Shores Village County Miami -Dade Zip 331 le g
FOLIO / PARCEL #
Is Building Historically Designated YES
Architect/Engineer's Name (if applicable)
0(50 00
R
1 MO
Type of Work: ❑Additi Y Alteration
Describe Work : VI
Value of Work For this Permit $
Notary $
Scanning $ Radon $
Miami Shores Village � G;
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: 305) 795.2204 Fax: (305) 756.8972
D MIMIC
DEC 0 4 2008
Electrical Plumbing Mechanical
316 N& 1 l2- l errztce-
NO
Contractor's Company Name
Contractor's Address
City
Qualifier Name
State Certificate or Registration No.
Submittal Fee $ Permit Fee $ (4
Training/Education Fee $ V ° o[/J
DPBR $
Bond $ Code Enforcement $
Structural Review. $
Permit No. P Nac, ° 2._q e�
Master Permit No.
Phone #
Phone #
Zip
Phone #
f Competency No.
one #
Square / Linear Fo t r"ge?Qf Work:
Double Fee $
❑ Repair/Replace
***************************************F es ********************************************
CCF
Technology Fee $
Total Fee Now Due $
_ C
�i /
Zoning $
Coq - 6C
See Reverse side -+
Roofing
❑ Demolition
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 At'NIDAVIT: 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 bu permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commence ' construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the bu lin rmit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charge
Sign:
Print:
My Co sion Expires:
APPLICATION APPROVED BY:
(Revised 02/08/06)
Owner or Agent Contractor
The fo regoing instrument was ackn wledged b fore niF this 4 The forego u s . \ ent was acknowledged before me this
�-
day � 2C6, f , 2, by L.0 e t J1raf , day of 20 , by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY ' IC:
NOTARY PUBLIC:
Mabel V`:cgw;,
007 . Sign:
Print:
My Commission Expires:
/Z( / ac
Plans Examiner
Engineer
Zoning
Date: Q 4
Owner's Na e: M i 1 I e- Po Luta, Phone #: 306 141 2224
Job Address (where the work is being done): 3 0 A no 1 t Z
City: Miami Shores Village County: Miami -Dade Zip: 331 tog
Is Building Historically Designated ?: YES NO V
Contractor's Company Name (if applicable): Phone #:
Walls: corn Si I K.
Fascia:
Drip Cap /Drip Edge:
Soffit:
Roof: 4) hI1Ci
Flower Bins:
Shutters:
Awnings:
Chimney: ` n l
Doors and Door Jams: W V 1
Garage Doors:
Railings:
Fences:
Signature:
Miami Shores Village
Paint Color Approval and Agreement
All elements on the site must be listed and indicate the color to be minted
to hi*,
1-7/cpp_
Decorative Metal:
All brick (simulated or regular): �.
Stucco Banding:
Any other Stucco Features:
Accessory Buildings:
Other:
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in comp1j ce with all appli laws regulating construction and zoning.
Owner or Agent
APPLICATION APPROVED BY:
P & Z OFFICIAL
Attach color Samples
with numbers
!) a
Flat
Date: Pt
Date: c(=' (
* *MUST BE ATTACHED WITH PURPLE BUILDING APPLICATION **
Corn SH
40YY 77/24;