ACT-09-1982(oft
BUILDING
PERMIT APPLICATION
FBC 20
Job Address (where the work is being done) _9800 M, /A /
Contractor's Company Namep
Contractor's Address 60/
'Contact Phone (7/54 )2999 -- z v0.
Architect/Engineer's Name (if applicable)
‘ 6°C2M/
Value of Work For this Permit $
Type of Work: ❑Addition
Describe Work:
* * * * * * * * * * * * * * * **
Submittal Fee $ "
Notary $
Scanning $ i
Double Fee $
Structural Review. $
Radon $
;Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
Permit No.AC C14 q g
Master Permit No.
Permit Type: BUILDING ROOFING.
Owner's Name (Fee Simple Titleholder) Al.) A.G. IS t:. LLL AC*0S T\ r..) 1
Owner's Address 98c0 ■• A/1 / Q jyt i A v ,
City M. /AAA S -IORe3 State FL_ Zip a5/ /
Tenant/Lessee Name Phone # 786 o?%G 3 7/1
Email
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL # J - 21 O I_ O 3 -CXD O
Is Building Historically Designated YES NO X
fl-41 1
k /e
Cityjf State f c Zip
Qualifier Name 101,l_S Tficz.0 Phone #
State Certificate or Registration No. Certificate of Competency No. 0'], S 0 /3,;,;
❑Alteration
G i.✓y11
E - mail C �G+Zpi'1
Squire / Linear Footage Of Work:
/ ew y ❑ Repair/Replace
* * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Permit Fee $
Training /Education Fee $
DPBR $
Violation date:
4 0
Phone ft
A vE
Phone #
CCF$ - 1';-c
Total Fee Now Due $
0 1 2009
BY: ........
78 -37 /
33/5_o
Bond $
Flood Zone
Phone (7 g,6) 2- toy.5;6
* * * * * * * * * * **
CO /CC $
Technology Fee $
See Reverse side -+
3 le s7 �
❑ Demolition
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.
Signatur
Owner or Agent
The foregoing instrument was acknowledged before me this,
day of ,209 , by xi ,nagvsz& 4,c s7 /s4J
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUB IC:
APPROVED BY
(Revised 07 /10 /07)(Revised 06/10/2009)
Plans Examiner
Engineer
Signatu
The for going in trument was acknowledged before me this '3
day of , 20 07, by Lowe'' =.S l `dt 2•etQ ,
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Contractor
'-� ! Zoning
Clerk checked