MC-07-571Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (315) 795.2254 Fax: (315) 7561972
BUILDING oal�lrn
PERMIT APPLICATION V�' '
FBC 2004
RECEIVED
Ml+R 2301
sx:,_jILD
Permit No. I4C 14•671
Master Permit No.
Permit Type (circle): Building Electrical Plumbing
Owner's Name (Fee Simple Titleholder) kg/ 7/i / % /Q6
Owner's Address $ 9 5 AI z 9 5 577
City %?/1 okii/irxeDIQes State JAL
Tenant/Lessee Name
Phone #
Roofing
Zip 32/g eP
Phone #
Job Address (where the work is being done)
,ore 9s sr
City Miami Shores Village County Miami -Dade
FOLIO / PARCEL #
Is Building Historically Designated YES NO X
Zip a
Contractor's Company Name ,Qa1/)4,UCE0 i )i Co &14 //I C Phone # 3 0 S- is.- 8 I
Contractor's Address / y6 t / N a / Rd 40
City ill' 111 State Zip 35 / d?
Qualifier Name 2E A / C6e/ s C G j d ° Phone # 7 2 . 2 . 0 867-
State Certificate or Registration No. C7 9C D 55/6 9 7 Certificate of Competency No.
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
980o
4(A9
Phone #
Square / Linear Footage Of Work:
Type of Work: ❑Addition ❑Alteration ['New Repair/Replace
/� ❑Demolition
Describe Work: ze,f 4 U x /.577 ti� •9 //e , /�QND L e' /ma)
G ow /0 6Als/ ti F- Gt.rl /? s8 /JD e,�'G G- ul /,' Arm'c v
x) 4) .6" joti sfZ /T s5/S7Cm
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees*****-'******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee�$$ Permit Fee $ v' V CCF $ C /CC
Notary $ �' (� � Training/Education Fee $ 02" Technology Fee $
Scanning $ 300 Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $ • G, %
See Reverse side —>
qp--e
Bonding Company's Name (if applicable) fi11
Bonditi p� Address
City �,,*�+jj State Zip
Mortgage Lender's Name (if applicable) N/
Mortgag ►dress
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 ,'tice, the
inspection will not be approved and a reinspection fee will be charged.
Signature /fr — Signature / _e. •t ( iAi
Owner or Agent / Contractor
The foregoing instrument was acknowledged before me this 23 The foreg r' , _ ' strument was ackno Ledge. ore me
day of IIItvdt , 20 , by 1 Ql L nf'd R(OO , day of �! , 20� byJJt►n
who is personally known to me or who has produced /% yNt Ltwho 's per onally own to me or who has produced
As identification and who did take an oath. ; . de; as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
- i, sit AV 1 a
MOKALISSETHDIAZ
`yam - MY COMMISSION # DD 483995
�: EXPIRNNo October. deePgers
pCk Li 53e
My Commission Expires:
NOT
Sign:
Print:
UBLIC:
My Co m'ssion Exlaires: , o
********************************************************************************41444************************
APPLICATION APPROVED BY:
(Revised 02/08/06)
c-)--0 312147
Plans Examiner
Engineer
Zoning