FW-11-689Miami 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 ROOFING
OWNER: Name (Fee Simple Titleholder):
Address: I 1 _ l
City: k c J
Tenant/Lessee a
Email: re+ C .
State:
Permit No.
�.N APR 1 9 2
Master Permit No.
pl►�lne#: 30S:—.S-efic1-276€7
Phone #:
Zip: 3 > r3 E_
JOB ADDRESS: 12A 1 Na (e\ M s
City: Miami Shores
Folio/Parcel #:
County:
Miami Dade
Zip: 331 3
Is the Building Historically Designated: Yes NO i�/ \® ood Zone:
O to (N eY , cR. � 1 — 5 r76
CONTRACTOR: Company Name: -, C ' Phone#:
Address: AA ‘�A 1 Oa Io1
City: k (A S [ :3 State: (___ Zip: 33
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ 1 , D 00 Square/Linear Footage of Work:
Type of Work: Addition UAlteration ❑New ❑Repair/Replace ❑Demolition
Description of Work:
VI\Ct MOODAILk/ /MOP VEX)CE._ TALL
***************************************Fe ********* ****+ x**** *****+x+x**** ** ****** * * * ****
Submittal Fee $ (.3 Permit Fee $ f 400 CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ '� a
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 AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEM
Notice to Applicant: As a condition to the issuance of a buildin= e� iran estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commenc '; "onstruction lien law brochure will be delivered to the person
whose properly is subject to attachment. Also, a certi < o e recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) da wilding permit is issued. In the absence of such posted notice, the
inspection wt . t be approved and a reinspec ' >` e charged.
Signature Signature
Owner or Agent
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
Contractor
day of , 20 _, by , day of
, 20 _, by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: - Print:
My Commission Expires: My Commission Expires:
*x:+ x+ x*+ x*****x: ***** ***m********** **************+ x*+ x******** **** ******x+*a:**+x+x+x*** ** ***** * ** *** ***+x***+ ***
APPROVED BY 7 /' Plans Examiner )4 It Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
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