DS-11-1103(t9 k
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 11 �� No. 1 I l ` ` �J 3
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING ROOFING
Master Permit No.
OWNER: Name (Fee Simple Titleholder): /3 '67Y'Y7 U- �-*C, F i" Ci! S Phon C , 523-37D7
/
Address: 93387 N(.t) 2 er
r,
City: /"/1Gih'1I .Sh.ar€,s State: FL Zip: 433150 .
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: /33! NW 2 er
City: Miami Shores County:
Folio/Parcel #:
Miami Dade
Zip: 33156
Is the Budding Historically Designated: Yes NO Flood Zone:
CONTRACTOR: Company Name: N DT USA hG . Phone #: �-c.(/ y 77(
Address:
3a5� MW eve •
City: Opel. _ tbe k4. State:
Qualifier Name: W4r € 4
State Certification or Registration #: 66,6 — / O ct rt.
Zip: , 3 059
Phone #:
of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Valve of Work for this Permit: $ / Q' a G} d Square/Linear Footage of Work:
Type of Work: Xbiddition T]Alteration UNew , f ORepair/Replace
Description of Work: ejGi8h,S ;phi Of G1 ri Vet/./
y
ODemolition
Submittal Fee $ Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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
Si gnature � 00-4,
The forego
day of
who is pe
Otei r Agent
instrument vo gl..edaed before me this
,20 1l, by
nally known to me or who has
As identification and who dii
NOTARY ' LIC:
Sign:
Print:
The foregoing instrument w wledged before me this 03 .
day of 20 �'��
who is personally known to me or who ha produced
as identification and v dW. take an oath.
MARIELA ,',.EDI
•a: m°i COMMISSION # DD820202
My Commission :± pires:
APPROVED BY
�ao71�s,:
Plans Examiner
NOTARY P . C:
ft
Sign: 0 Ai
Print i'
My Commission
MMARIELA MEDINA
ON # DD820200
EXPIRES September 04. 2012
/7/ Zoning
Structural Review Clerk
(Revised 07 /10/07)(Revised 06/ 102009)(Revised 3/15/09)