WS-10-1985\\\N)Vo-Vko*frc64z--
i?t
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
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING
OWNER: Name (Fee Simple Titleholder
Address: /I g Mk) l ) 97-
City: 14-f! 1° 4-✓7
Nov 0 9 MO
oermi,No4S10-19d5
Master. Permit No.
Tenant/Lessee Name:
Email:
State: F I
Phone #: /7qQ — /604-
Zip:
E / Phone #:
33150
JOB ADDRESS:
City:
Folio/Parcel #:
Miami Shores
Cou
II-3101- Dd-
Miami Dade
Is the Building Historically Designated: Yes O 4 J
CONTRACTOR: Company Name: M 1 t1 i !2. .
Address: /34(00 /1/ W 5 ° /*lie .,
City: N, LA i a rn i State:
Qualifier Name: VI C.-TD 2 a , S dvy1C-17✓
Zip: 35 1,50
Flood Zone:
Phone #: 7P/5/Ifr /o35
Zip: 3 % 8
Phone #: 7k0 5' -103-5
State Certification or Registi ation #: C Ca,C 1 rj 7P- Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer:
•
A
Phone #:
Value of Work for this Permit: $
Type of W
Descripti
Square/Line
j�]New
LIRe try MOR1
GN140 - di: 1 p
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
Submittal Fee $ Permit Fee $
/J2
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ A• i N
Bonding Company's Name (if applicable)
Bonding Company's Address [ /
City State l 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 afier 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.
Signature
rtliA
Owner or Agent
The foregoing instrument was acknowledged before me this ®Z‘/' The foregoing instrument was act 'fled before me this.29
dye of f) y /� 4-/Z.- day ofi , ZO %0, by if, SG(
who is personall kno mho e . h o &L +jocac
As identification and who an oath.
NOTARY PUBLIC:
Sign:
Print:
My Comm
APPROVED BY
who is personally known to me or who has>
as identification and who
NOTARY PUBLIC:
/0/40-/O Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 0 611 0 /2 0 0 9)(Revised 3/15/09)(rev6/4/10)