DEMO-10-180Miami Shores Village
Building D epartment
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 No.
'"D
Master Permit No.
Permit Type: BUILDING ROOFING.
Owner's Name (Fee Simple Titleholder) 011.160 50173 Phone # a(} 6 (30d-Y\
Owner's Address N�. ? 5 \ , � �1
City \.%1O1,- 1 cfe) State FLC CQ
Tenant/Lessee Name
Email
Zip
Phone /4
Job Address (where the work is being done) U9- b Er
City
FOLIO / PARCEL #
Miami Shores Village
County
Miami -Dade
Zip ca '31
Is Building Historically Designated YES NO Flood Zone
Contractor's Company Name
Contractor's Address
City
Qualifier Name
State Certificate or Registration No.
Contact Phone
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: ❑Addition
Describe Work:
E -mail
Certificate of Competency No.
Phone #
Square / Linear Footage Of Work:
❑New ❑ Repair /Replace
Demolition
111,u o�n
************ *, * * ** * ** * * * * * * * * * * * * * ** * * * * * ** Fees************* * * * * * * * * ** * * * * * *** * * * * *** * * * * **
Submittal Fee $ "--?;0 •OPermit Fee $
Notary $ ' 'UV Training /Education Fee $ O��
Scanning $3' GO Radon $ DPBR $
Double Fee $
Violation date:
CCF $
CO /CC $
Technology Fee $ Q -
Bond $
Structural Review. $ Total Fee Now Due $ 541.(00
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 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
promise in good faith that a copy of the notice of commenceme
whose property is subject to attachment. Also, a certifie
for the first inspection which occurs seven (7)
inspection will not be approved and a reinspec
Signature : ( U C d c.1 ' ature
ith lue exceeding $2500, the applicant must
law brochure will be delivered to the person
notice of commencement must be posted at the job site
g permit is issued. In the absence of such posted notice, the
Owner or Agent
The for oing instrument was a
day ofd , 20 JO, by
•I 'wledge• before m
�' lei
is
w o i personally known to me or who has produced
2O)
J
identification and who did take an oath.
NOT
Sign:
Print:
My Commission Expires:
4t 15 % os:
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 _, by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
APPROVED BY 0� � Plans Examiner . /c/0 Zoning
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
Clerk checked