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RCRT-09-439BUILDING PERMIT APPLICATION FBC 20 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 W W W.MIAMISHORESVILLAGE.COM Permit No. 1 M Master Permit No. Permit Type (circle): Building An Roofing Owner's Name (Fee Simple Titleholder)' " 'I Q1 t I I %CMS k f L� Owner's Address City State Zip Tenant/Lessee Name Phone # Email Job Address (where the work is being done) City Miami Shores Village Coun Miami -Dade Zip FOLIO / PARCEL # ( EazQ -O�� - l!1 Is Building Historically Designated YES NO Flood Zone Contractor's Company Name Phone # Contractor's Address City State Qualifier Name Phone # State Certificate or Registration No. Contact Phone Zip Certificate of Competency No. E -mail Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ Type of Work: ['Addition Describe Work: ********* * * * * * * * * * * * * * ********** * * ** *** F * * ** * * * * *** * * * * ** **** ******** ** Submittal Fee $ Notary $ Scanning $ Bond $ ['Alteration Structural Review. $ Square / Linear Footage Of Work: oG ( 145 DNew ❑ Repair/Replace ❑ Demolition 9c7 • Uture18,. Permit Fee $ pL \U CCF $ CO /CC Training/Education Fee $ Technology Fee $ Radon $ DPBR $ Zoning $ Code Enforcement $ Double Fee $ Total Fee Now Due $ 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, 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 of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of , 20 __ by 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 PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: Print: My Commission Expires: My Commission Expires: ******** * * * * * * * * * * * * * * * * * * ***** *x: **** : ***** ** *: ****************************** * * * ** * * * *** * * *** **** * *** * ** **** APPLICATION APPROVED BY Plans Examiner Zoning (Revised 07/10/07) Engineer Clerk checked U.S. Postal Service. CERTIFIED'MAILT. RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) For delivery information visit our website at www.usps.com© Postage CeriMed Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Fees Postmark Here PS Form 3800. August 2006 See Reverse for Instructions Certified hell Provides: ® A mailing receipt a A unique identifier for your mallplece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mall may ONLY be combined with First-Class Maile or Priority Mahe. c Certified Mall is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mall. For valuables, please consider Insured or Registered Mall. In For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3911) to the article and add applicable postage to cover the fee. Endorse mailplace Return Receipt Requested °. To receive a fee waiver for a duplicate retum receipt, a LISPS® postmark on your Certified Mall receipt Is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent Advise the clerk or mark the mallplece with the endorsement °Restricted Delivery°. E If a postmark on the Certified Mall receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mall receipt is not needed, detach and affix Zabel with postage and mall. IMPORTANT: Save this receipt and present It when making an Inquiry. P3 Form 3800, August 2006 (Reverse) PSN 7530-02-000-9047