SGN-09-1075Miami Shores Village
Building Department IrECW1
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 J1JN 2 6 2007
Tel: (305) 795.2204 Fax: (305) 756.8972
BY:
BUILDING Permit No.9214 Oct - Cis •
PERMIT APPLICATION Master Permit No.
FBC 2004
Permit Type (circle):
Owner's Name (Fee Simple Titleholder) AC °�` ', / 'a ff Phone # L/12 2 fo
Owner's s� Address pq 3 `i 4 £ 2 n 11"e
City 1`%! a M r `R Oi" State l` ce d4- Zip / �
Tenant/Lessee Name .' (4 � 41 ef�e✓ /14 7rr (P/1 e r r � /-i Phone # 2') 7f 9' y' ePt
Roofing
Job Address (where the work is being done) 9 `7 � i
City Miami Shores Village County Miami -Dade Zip 3 3/31
FOLIO /PARCEL# II-3206 -013 -?_3`fC
Is Building Historically Designated YES NO X
Contractor's Company Name
4/(A
4
Phone #
Contractor's Address
City State
Qualifier Name
State Certificate or Registration No.
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $ Square / Linear Footage Of Work:
Type of Work: ❑Addition aAlteration
( ,n
Describe Work:
I i\ JWrr; e /acu fed,
['New Repair/Replace
p/.4 1',774 /
Demolition
******** ** * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ CCF $ CO /CC
Notary $ Training/Education Fee $ Technology Fee $
$
Scanning $ Radon $ DPBR $ Zoning
Bond $ Code Enforcement $ Double Fee $
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 CONDITI RS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accuri
1te
t all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A
PAYING TWICE FOR IMPROVEMENTS TO YOUR PR
CONSULT WITH YOUR LENDER OR AN AT
COMMENCEMENT."
Notice to Applicant: As a condition to the issuance o
promise in good faith that a copy of the notice of co
whose property is subject to attachment. Also, a ce
F COMMENCEMENT MAY RESULT IN YOUR
IF YOU INTEND TO OBTAIN FINANCING,
BEFORE RECORDING YOUR NOTICE OF
permit with an estimated value exceeding $2500, the applicant must
nt and construction lien law brochure will be delivered to the person
bpy of the recorded notice of commencement must be posted at the job site
for the first inspectio hich occurs seven (7) days er the building permit is issued. In the absence of such posted notice, the
inspection will not b roved and a reinspection fee will be charged.
Signature L Signature
Owner or Agent ` Contractor
The foregoing instrument was acknowledged before me this The - 'ng instrument was acknowledged before me this
day of , 20 , by , 20 _, by
Os who is personally known to me or who has produced 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:
APPLICATION APPROVED BY: Plans Examiner
Engineer
Zoning
(Revised 07/10/07)