RC-08-2052QIN
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BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Owner's_Address
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Owner's Name (Fee Simple Titleholder)
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City � fl) cijTh �i `� State l� zip I 07
Tenant/Lessee Name Phone #
Job Address (where the work is being done)
City
FOLIO / PARCEL #
Miami Shores Village
Is Building Historically Designated YES
Contractor's Company Name
Contractor's Address 5 0
City (C r
1
Qualifier Name C Ll 1
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: dAddition
Describe Work:
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Submittal Fee $2
Notary $
Scanning $ Radon $
Bond $ Code Enforcement $
9200 N . PDcty ysho I Miami -Dade Zip 3 3 ) 3 8
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State
State Certificate or Registration No.
4p,
4c,00
DAlteration ❑New
OM On E
Training/Education Fee $
Pica. f Competency No.
Phone #
Square / Linear Footage Of Work:
f 4 4 ***** * * * * * * * * * * * * * * * ** * * * * * * ** * * * * ** *F * * * * ** * * ** *:* * ** *:* **
See Reverse side -�
B Y:
Permit No. kC0 - 9 -0 52
Master Permit No.
Phone # k ; 30 5 . — 1 5' U • 2:30
C�
63. 0080
Zip a 5 I . pp
Phone# ""5 4-(01 '00 C�
78G-Sq -G- 5a4
4 s 2 41
❑ Repair/Replace ❑ Demolition
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Permit Fee $ CCF $ CO /CC
Technology Fee $
DPBR $ Zoning $
Double Fee $
Structural Review. $ lirg 6v• Total Fee Now Due $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Artirpce
Application is litettei rinatitii to :obi:it:nip the tintrit. inn] ntiitiain.ition.s as. innicateitl. th.at no work or installation has
commenced prtor to ine Issuance oe nieritint „inns ntitt ittorti pith itettniiiied to IY:e4.n the shnuards ietti all laws regula.tmg
construction 3.n. Tilts Jurisdiction. .L 111.1idelariCi. Mat a SCI)arate peimilt mititt be secured ler niteitt.0 .H.teNii.131Nti
\ 1 FICtft Lat 7 an d i ii„JJ„i_ oen relic
OWNER'S AFFIDAVIT: , r0 7 ".. - e .,•'• and that •Etri etopt, h.1 clone m compliance with all
apphcalme laints
"WARNING TO OLVNER: YOUR .FAILTRE TO RECORD NOTICE OF CONLNIENCEMENT MAY RESULT IN YOUR
PAVING TWICE FOR 1 NIPRON'TEINIENES TO YOUR PRO VEIRTY% IT YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH 'N01in 'LENDER OR "AN. ATTORNEY BEFORE RECORDING 'YOUR NOTICE OF
COMMENCEME
. /Vol.ice t (i) 000co ito itiortanetiti tit! a iiiite-',.qt7i0 0 4/11/01(a.1 the applicant
proinRc !ia !olf 6r,a4 12'LPC :deilveTed to 1/ ]k (71/
srhosty ft/tope/1y , :intiteti - ti ?it oer#414tit• tielty i/oPeii 1 818 8 8 / 8/ 18 be posted at the job site
JOT the liTst inspt-sodoo : ;itays 8 7iC:h posted notice, die
itt,spectioti. .,:,Tto-,: / 7,i7 , 1)411 bu
The foregotmg inst.; ument nth; :.cfienneeletfccdt it 25th 7017 , tcknoioledLted befeirepae this
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'Ja ugust - CZ
Richard J. Haft - g
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who i personally iettivtri n s Ally kPC :0110 e.:i0 hits i
NOTARY PURI.
Slgi
State Certificate or .ktectistranon
(Revised 07/10/07)
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J, STEIN
ratorrhio iroyFainTriOiranOillNa-fdTh
cs3VE. 4 conni,,:,.aLe
ttl'ine,,e10(
its itientthectiiitm anti 1/I/o did take an oath.
)
Expires April 3011
Print: / C2 SILVIA MATARAZZO
No PUbk • State of Honda
41.04 Commission Expires Oct 31, 2009
*******************************************,•,*,-,-*************-,:,*****,•,„**************,,. .......****CananissiortlIDD497,063
, ....•
(Certificate of Confpeteno: Holder) *moo Bonded By National Notary Assn.
APPLICATION APPROVED BY: Plans Examiner
Engineer
Zoning