DS-09-1754Miami 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
INX(OMIMMTI
la OCT 2 6 2009
B Y:
�...�.0
Permit No ( -1 _I 15r
Master Permit No.
Permit Type: BUILDING ROOFING.
Owner's Name (Fee Simple Titleholder) 1.' Phone #
Owner's Address
City
Tenant/Lessee Name
Email \ 4 �!
State b__. Zip
Phone #
Job Address (where the work is being done)
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated
Contractor's Company Name
Contractor's Address
City
County
Miami -Dade
Zip
Qualifier Name \ l
State Certificate or Registration No. Certificate of Competency No.
'Contact Phone
Architect /Engineer's Name (if applicable)
Value of Work For this Permit $
E -mail
Phone #
Square / Linear Footage Of Work:
Type of Work: ['Addition ❑Alteration ['New [3 Repair/Replace
Describe Work:
❑ Demolition
c,,v''SC&_. .., ... .mss
.Y. �,� ****** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ D 00 Permit Fee $ CCF $ CO /CC $
Notary $ Training /Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Bond $
Double Fee $ Violation date:
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)
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 building permit with an esti .
promise in good faith that a copy of the notice of commencement and
whose property is subject to attachment. Also, a certified c
for the first inspection which occurs seven (7) day
inspection will not be, approved and a reinspection fe
Signature)( P
The for
day o
who
Owner or Agent
- to n:. instrument was ackno
ledged before • thi: 1/` •
ersonally known
or who has produced
As identification and who did take an oath.
NOTARY ' UBLIC:
Sign:
Print:
a L O,
eding $2500, the applicant must
e will be delivered to the person
mmencement must be posted at the job site
is issued. In the absence of such posted notice, the
Signature
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.
My Commission Expires:
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
************************************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPROVED BY Plans Examiner
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
c ' Zoning
Clerk checked