DS-10-1593R
Permit No.
Owner's Name (Fee S' nple }tleholt
Owner' ,Address
i - -
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING
City d it 1 fP
Tenant/Lessee Name Phone #
Email
Job Address (where the work is being done)
City Miami Shores Vi
FOLIO / PARCEL #
Is Building Historically Designated
Contractor's Company Name
Contractor's Address
City
Qualifier Name
Zip
Phone #
State Certificate or Registration No, Ce Competency No,
Contact Phone B -mail
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: DAddition
Describe Work:
State
t
State
Alteration
t -Ltd;
Submittal Fee $ /
Notary $ Training/Education Fee $
Scanning $ Radon $
Double Fee $
Structural Review.
:iarnl Shores Village
Building Department
0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795,2204 Fax: (305) 756.8972
SPECTION'S PHONE NUMBER: (305) 762.4949
DPBR
Master Permit No,
Phony
Zip 65f J/
mit Fee $ CCF
on date:
Flood Zone
Phone #
Phone #
Square / Linear Footage Of Work: < ..'
❑New ❑ Repair/Replace 0
* * * * * * * * ** * * * * * *
COI
Technology F
Bond $
Total Fee Now Due $
See Reverse
Bonding Company' Nance (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
Signature
q Zip
Applicatio is aert y na 1e obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to a issaaavice of a permit and that all work will be performed to meet the standards of all laws regulating,
construction in thi jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PIANBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC.._
OWNER'S IDAYIT: I certify that all the foregoing information is accurate and that all work wilLbe cloud in co bian e with ail`
applicable laws regulating construction and zoning.
Qwne or Agent Contractor
The fore Ding instrument was acknowledged before me this The 14zr e ei instrument was acknowledged before nie this
ay of 5 20 ILL, by vl' 1 day of ,20_,by
who is personally known to me or who has produced R ,..- ') who is personally known to ine or who has produced
As identification and who did take an oath. as identification and who did take an oath.
� �1541 11 I
NOTARY l'i1BLICt ``,,,, �'®Oc,k',i °,,<
Signs : T s., °
Prtut : - • cA „y.
My Co tui sstcrn Expires; • � -6
*
APPROVED BY
(Revise(1 07/10 /07 Revise4 06/10/2099)
NOTARY PUBLIC:
My Commission Expires w`
Zoning
Clerk checked
Notice to Applicant: As a condition to the is of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notic cc t encement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a 4" z ' o ; - opy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days ;' , e building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a rei <spection fee wi `�� ged.
Plans Examiner
Engineer
a t t i r e
* **
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE O
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FO
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAI
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.”
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