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BUIL IN
PERMIT APPLICATION
FBC 20
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 Type: BUILDING R'
Owner's Name (Fe Simple Titleholder)
Owner's Address ` � ? 'fo A16— 1,03
City /P9 w , am(' 1 S State -
OFING
MAY 262010
Permit No.O-1T N, 0 —(=? 1
Master Permit No.
Phone # "O5 — 2-0 q3--t3
Tenant/Lessee``N��ame
Email fit. (And WI CLIfir. ! p op • C-evrn
Job Address (where the work is being done)
Phone
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL #
Is Building Historically Designated YES NO Flood Zone 41 Q
Contractor's Company Name /1o)'?uitThJ tt'7e Phone #
Contractor's Address
City State
Zip
Qualifier Name Phone #
State Certificate or Registration No.
Contact Phone
E -mail
Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ t
Type of Work: ❑AAdddition ❑Alteration
Describe Work:
Square / Linear Footage Of Work:
ew
❑ Repair/Replace ❑ Demoliti
******** * * * * *** * * * * * * * * * * * * * * * * * * * * * * ** Fees * * * * * *** * * * * * * ** * * * * * * * * * * * *** * * *** * * * * * * **
Submittal Fee $ Permit Fee $
CCF $
Notary $ Training/Education Fee $
Scanning $ Radon $ DPBtt $
Double Fee $ Violation date:
Structural Review. $
CO /CC $
Technology Fee $
Bond $
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 W ORK, 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is su' ''ct to at t'...'. en lso, a certified copy of the recorded notice of commencement must be posted at the job site
for the first insPef whit oc d seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will e appr . ed d a reinspection fee will be charged.
Signature
The forego'
day of
who is
Owner or Agent nn
owledge4 before me this Gl ( 0
b'r
g instrument was ac
Signature
Contractor
The foregoing instrument was acknowledged before me this
Hof ,20,by
kno7 to me or who has produced? I G who is personally known to me or who has produced
Irks identification and who did take an oath. as identification and who did take an oath.
NOT ' Y, PUBLIC: NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Sign:
' Print:
1�l .
My Commission Expires:
ea,ee.`�
** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** sY1r*de$t*3 *** *t9e4e3r4e********* Y*4t:Y********9rtklr*** 9: it ** , tkzk ** **3e*9r*** **3c*9e ******
APPROVED BY
Plans Examiner
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
Clerk checked