FW-09-1790ur) 11/5
BUILDING
PERMIT APPLICATION
FBC 20
Email
Contractor's Company Name
Contractor's Address
City
Qualifier Name
Contact Phone
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTI I ONE NUMBER: (305) 762.4949
Permit Type: BUILDING ROOFING
Owner's Name (Fee Sim .le Titleholder . ' /1 i , 1.1 Phone # j___ �f //'
Owner' Address % . / �1lr ,E
City J 00PS State
Tenant/Lessee Name
Permit Nof V /U - 0 % / 790
ster Permit No.
Zip ,TyG.
Phone #
Job Address (where the work is being done) ,l ,/g ileve
City Miami Shores Village County Miami-Dade
FOLIO / PARCEL #
Is Building Historically Designated YES NO 4/ > `' Flood Zone
Zip
Phone #
State Certificate or Registration No. Certificate of Competency No.
E -mail
Architect/Engineer's Name (if applicable) 01 Phone #
Value of Work For this Permit $ 25 Da Square / Linear Footage Of Work:
Type of Work: ['Addition ) ['Alteration ❑New ❑ Repair/Replace ❑ Demolition
Describe Work: 2. 90, e 0l(fMlrli f?!l
* * * * * * * ** ** * **im * * * * * * * * * * * * * ** * * * * * * * * *F * * * * * * * * * ** * * *, * * * * * * ** * ** * * * * * * * * * * * * * * * * **
Submittal Fee $ V / V Permit Fee $ CCF $ CO /CC .$
Notary $ 5.0o Training/Education Fee $ Technology Fee $
Scanning $ . (' 0 Radon $ DPBR $ Bond $
Double Fee $ Violation date:
Structural Review. $ 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 prnut "iwjlh estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commesa t r�cLt ns"truction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certifie copy Pile recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (' )4as�af the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a re pehtion fee will be charged..
,Signature
APPROVED BY
Owner or gent
(Revised 07 /10 /07)(Revised 06/10/2009)
The fore g instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of f • , 20 b}J p ` kLatja f S , day of , 20 _, by
who is personally known to me or who has produced rL L. who is personally known to me or - who has produced
M T3 (# 90 As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: . L _ �1.1. / L 4 I /t %1
. t/
f " ,
Print: At, 1-1-
Av,f
My Commission Expires: ' - =\I . 1b
F .f� �,14 444 4, •
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Signature
Contractor
Sign:
Print:
My Commission Expires:
Plans Examiner Zoning
Engineer Clerk checked