MC-10-1724Miami 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 f
Permit No. m k V ' �` 1
Master Permit No.
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: MECHANICAL
Owner's Name (Fee Simple Titleholder)arri 13471, 6Nk_ oc--FLEti. 1 CZ • Phone #
Owner's Address 2 Ocrsr —r �� �, ,., a* 711
City v (A vAt State ` ,�' ' Zip .3)30
Tenant/Lessee Name j ". 0V12.. Phone #
Email
-754.774 7
Job Address
City
FOLIO / PCEL #
Is Building Historically Designated YES NO
Contractor's Company Name
Flood Zone
onee# (944 5 l I'�SS1
Contractor's Address 1.06 01 L- b* ,p,4' gt)1 TE T '- VA) ` -' te" W V (
City C „OIW? t~' le- State -F Zip 3 .. 7 3
Qualifier Name j F Tilotioks g Nj Phone t :t� 3 "0337
Certificate of Competency No.
State Certificate or Registration No. CAC, I 1 t OZ E
Contact Phone_ 9 ) i. 4438, E -mail
Architect /Engineer's Name (if applicable)
Phone #
Value of Work For this Permit $ S, uare / Linear Footage Of Work: t19
Type of Work: ['Addition ['Alteration New ❑ Repair/Repl NoVlo molition
Describe Work:
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ees * ** ** ***** * * * * * * * * * * * * * * * * ** * * * * * * * * * * * **
Permit Fee $ CCF $ CO /CC $
Submittal Fee $
Notary $
Scanning $
Double Fee $
Training/Education Fee $
Radon $
DPBR $
Violation date:
Technology Fee $
Bond $
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 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, ins. ; on which .occtiirs seven (7) days after: the building permit is issued. In . t4 absence of such posted notice, the
inspection wi not b approved and a reinspection fee will be charged.
gent
The.foregoin: ent was acknowle
day of ."Or, 20-(x, by
who is personally known to or who has produced
ntification and who did tak
NOTARY PUBLIC:
Sign:
Print: '
mg. instrument was acknowledged before me this g'L
cePr- , 20 ioo , by 3 '+4 ".►#:%�' ,
who is persoiiailyn or who has produced `;}C
as identification and who did take an oath.
NOTARY' PUBLIC:
My Commi
RI
rJTARY PUBLIC
STATE OF FLORIDA
Comm# 11ras DD97 311412014 15
e
t
* * * * * * * * * **
APPROVED BY
Sign:
Print: CArt240 ' __ --
My Commission Expi (cARDO E. BERMUDEZ
IC
NOTARY PUBL
STATE OF FLORIDA
�m# Dp971115
* * * * * * * * * * * * * * * * * **
&Plans Examiner
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
Zoning
Clerk checked