RF-11-2283PERMIT APPLICATION
FBC 20
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
1 „ ( � INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
�
Permit No.
1JV:
DEC 0 8 Z 11
BY.
Master Permit No.
Permit Type: BUILDING ROOFING
OWNER: Name (Fee Simple Titleholder): ST.,,0 A44)21 M9 Phone #:
Address: 12.1 'I hie (n--4•1^ . r-�l /_
City: M ► /t- Nb( g Al t-ic State: 'r - Zip: 33 �P i
Tenant/Lessee Name: Phone
Email: ..S A' to % VIA °' • G�
City:
Miami Shores
County:
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO eX
Flood Zone:
CONTRACTOR: Company Name: PI .. A\ 9 Phone#: ' & 1 7 0/C3
Address: i-Oq' ` !tie 'eR
City: 4,.. ! L
Qualifier Name:', ■ 1
Zip: / Cot
Phone#: Lcc---T6. ,y
State Certification or Registration #: 1 u ficate of Competency #: w l
Contact Phone#: eTh ' T ' ' ( Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $,
Type of Work: UAddition
Description of Work:
Square/Linear Footage of Work:
ONew DRepair/Replace
ODemolition
****+u************** * * * ** *************** Fees***** ********,x** ** *** * * * *** * *** x************
Submittal Fee $ Permit Fee $ .1 QQ° CCF $ CO /CC $
Scanning Fee $ Radon Fee $ ° ` ?' $ Bond $
Notary $ Traimn � �' r ee Technology Fee $
Double Fee $
TOTAL FEE NOW DUE $
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 co ncement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
wner or Agent
Signature
Contractor
The foregoing ins u 'ent was acknowledged before me this The foregoin,, instrument was acknow edged
day of MQAJ , 20 ILL, by Ste &PAZ _ , day of 1 , 201 ( , b
who is personally known to me or who has produced who is personally known to me or who has p odu' ed
As identification and who did take an oath.
JUAN ALBERTO BRUGO
MY COMMISSION /t
•
DD90806
07) 398 -09; 3 JU Y 15, 2013
My Commission Expires
APPROVED BY
Floridallo
as identification and who did take an oath.
Sign:
Print.
My Commission Expires:
/ 27 —l' Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06/I0/2009)(Revised 3/15/09)
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204 Fax: (305)756 -8972
For Inspections please call: (305)762 -4949
CANCELLATION OF PERMIT t •
•
•
/(V‘"6-A-Si.
This is a request for a cancellation of permit.
1/ .)a
Permit Number: Job Address: /2 '4 °1
Date:
Owner's Name: _co C 0 \ ; °' --0 Job Address Folio Number:
Owner's Address: - ;," of N-- S+-3
Phone Number:
CONTRACTOR'S INFORMATION: /1-+,
Contractor's Name: Address: / `=. el 67 331
License No: AS97 CO [ Sr3 Contractor's Phone: c � I / r
To Whom it MayConcern:
REASON FOR CANCELLATION: No work performed under this permit.
t„ (% No -(-- - t iv-rL. 1".)
1 /we certify that the above statements are true and represent an accurate account of the facts. Further, I /we agree to
hold the City harmless and relieve them from any responsibility or liability for any legal action or
damages, costs or expel..., including but not limited to attorney's fe ulting from th - ancel t- tion of the subject
permit or the issuance of a new permit.
Owner's signature
STATE OF FLORIDA
COUNTY OF MIAMI-DADE)
or
ontractor's signature
Before me, an officer duly authorized to take oaths and acknowledg -' y , personally appeared
, owner /contractor of the above mentioned property who is sworn to
,20
and subscribed before me this day of
Notary Public, State of Florida
(Print, Type, or Stamp Commissioned Name)
Building Official
•
Personally Known [ ] or
Produced I.D. [ ]
Type of I.D. Produced:
a