RC-11-1688Miami Shores Village
Building Department
/0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Roofing
Permit No.
RECEIVED
SEP152011
Master Permit No. J - 9 V 'y, 55
Owner's Name (Fee Simple Titleholder) t ! t:1 CA lin OLc WOW-) Phone #
Owner's Address ISO PE' 510 - e.
City \tl a State Zip 35
Tenant/Lessee Name
Phone #
Job Address (where the work is being done) V 0 k-10 b)t G 0 -4'e (
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL # p9- OWS -CO d -Oq ?C.0
Is Building Historically Designated YES
Contractor's Company Name 1L
Contractor's Address O 11J
City ���t 0 o6a State I ,
Qualifier Name
State Certificate or Registration No. Co co( t 1,c1 0 Certificate of Com
NO
Architect/Engineer's Name (if applicable) C'ThcAN i t (, Ue 1k-e- Phone # 3(.� t
Value of Work For this Permit $
Square / Linear Footage Of Work:
Type of Work: ['Addition ❑Alteration ❑New
Describe Work:
Lool
❑epair/Replace ❑ Demolition
* * * * * * * * **
* * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* ** * * * ** * * * * * * * * * ** * * * * * * * * * * ***
Submittal Fee $ .,-, Permit Fee $ CCF $
CO /CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $
Bond $ Code Enforcement $ Double Fee $
Zoning $
Structural Review. $
Total Fee Now Due $
See Reverse side
Bonding Company's Name (if applicable)
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State
Zip
Zip
Application is hereby made to obtain a permit to do the ork 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 isi: In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Owner or Agent
The foregoing instrument was acknowledge
day of ,20i j , byLLY1 \aC4
who is personally kno me or wii o s as produced
As identifica 'on i d who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Contractor
The foregoing instrument was acknowledged before me this L
,20'( , by L J &q ,bJcIv2
who is personally known to me or who has produced
as identification an o did take an oath.
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*
APPLICATION APPROVED BY:
(Revised 07/10/07)
**
NOTARY PUBLIC:
Sign:
Print:
My Commissi
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Plans Examiner
Engineer
Zoning