DS-10-993to Iy'∎0
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Miami Shores Village \,kt
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
�., y`'4) 'INSPECTION'S PHONE NUMBER: (305) 762.4949
ede5t, LL.
BUILDING‘-‘%1%)(C1 ,, ' ,.., 1`�
PERMIT APP ICATION�
FBC 20
tAAN1-1‘2,'' g X01
Master Permit No.
Permit Type: BUILDING ROOFING.
Owner's Name (Fee Simple Titleholder) p gvio '. 16e.Q.McNstx _e.t Phone #
Owner's Address \ °1.S
City c\t, r \ tkca
Tenant/Lessee Na
Jab , `ate ASS
Email
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3vS - (0`7°
30s- 0 Vi37 61}644=
kt -so Lakrk_ f\.Z
where the work is being done) \ a `J kr R. E. 0) a __ pp
Miami Shores Villa e County Miami -Dade
OLIO / PARCEL #
Is Building Historically Designated YES
Contractor's Company Name
Contractor's Address
Ng
YYR1/1 00,110('-r
Phone #
Fl�rod Zone
City
Qualifier Name
State
Zip
Phone #
State Certificate or Registration No. Certificate of Competency No.
'Contact Phone
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: ['Addition
Describe Work:
E -mail
• Phone #
DAlteration
Square / Linear Footage Of Work:
NeNit ❑ air/Replace
1�S [ O . NO
Demolition
Ulf
i�
* * * ** * * * *** ** ** * * ** Fees * * * * * * * * * * * * * * * * *** * * * * *** * ** * * * * * * * * * * * * **
c r?;tiA
Submittal Fee $ �"�
Permit Fee $
Notary $ Training/Education Fee $
Scanning $
Double Fee $'
Radon $
CCF $
DPBR $
Violation date:
CO /CC $
Technology Fee $
Bond $
Structural Review. $ 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) C. A, 0 Nekc
Mortgage Lender's Address J
City State Zip
Application is hereby made to obtain a permit to do t1, e 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.
Signature(
The forego
day of
who is p
or Agent
Signature
Contractor
wledge4 before me, this ON, 3 The foregoing instrument was acknowledged before me this
1,)ng day of , 20 , by
who has produced I'4, who is personally known to me or who has produced
NOTAR
Sign:
Print:
My Commission Expires:
tion and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
{�' , era
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u`T "';' r• ,gn:
.15gicfy ° ° Print:
My Commission Expires:
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APPROVED BY
Plans Examiner
Zoning
Engineer Clerk checked
(Revised 07 /10 /07)(Revised 06/10/2009)
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