EL-05-165BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building
Owner's Name (Fee Simple Titleholder) Iq►il as a.a,
Owner's Address 6 0 a Gi-a nurt�
City l� 4uti C b ) State
Tenant/Lessee Name
Job Address (where the work is being done) sco _ &. ct 01i4---
City Miami Shores Villa: e County M� Miami-Dade
i -Dade
V
Is Building Historically Designated YES NO
Contractor's Company Name 1344 116 }4,11 xf6 Phone # l7 9 (6) 3 90 - 9 213
Contractor's Address 32..s to.,Ril00 J 61 ._a t st,;ft,
Cit 41. a ' y $ State .F-L
Qualifier ` OA 0.4.0. I VL.4, , .1/
State Certificate or Registration No. VI E coo l i t
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit
Type of Work: ['Addition ['Alteration ['New [/ Repair/Replace [' Demolition
Describe Work: Qt 0,0fro , 5-ry R'tct. Rk+tfrl i
****************************F
*** * * * ****** **
Submittal Fee $ Permit Fee $ /VP/ +f CCF $ % •D -C)
Notary $
Scanning $ 3
Code Enforcement $
Total Fee Now Due $ r
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Training/Education Fee $
Electrical
o�000
Plum 5 n': Mechanical Roofmg
e vo ke_Phone
Permit No. E l- O 'j — / 5
Permit No.
Zip
Phone # — ti A
Zip
30 1 151-8 -4
3 3 (3f�
Certificate of CQS €ncy No.
Square Footage Of Work:
* **
Technology Fee $
Radon $ Zoning Bold $
Structural Plan Review. $
CO /CC
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 wi�i.estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construptiali lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded not,/p. ommencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is iss ;In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged
P
Signature{ u
Owner or Agent ,n
The foregoing instrument was acknowledged before me this i ti kiAi
day of M . ,200V, by S ; ,
who is personally known to me or who has produced L
Dtt* v As identification and who did take an oath.
APPLICATION APPROVED BY:
Chc 05/13/03
Signature
Co eto
The foregoing instrument was acluibkIL before me this N '
day of C ''r.9 , 20 ;' by � •
who is personall k known to me or who has produced
as identification and who did take an oath.
NOTA' PUBLIC: ����NIIIt /�
My NOTARY PUB IC: l++lSS4i
qg title
Sign. � :::3;‘*.k#11:1‘0:1111'.1R112 ODgj����� Q 9; � i o� Print: 9 � • s Commission Ex ices: c Y P My Commission Expires: #D D ; o 80062 ; ■
t, *, *u ar�r * ** ,�,�* ,��r�rt ,� *k *k � � *** *Ar, * .0 T�F * ,r * * * * * * * * * *,r * * * *,t * * * * * *� * * * * *,��tx * * *,r* * • ed *'�� Q�
% %,Ge� C A ` w� '/'� c A `r
o ��
Plans Examiner
Engineer
Zoning