RC-12-449Miami 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
Permit Type:
MAR 1
FBC20044CT .
Permit No. 2�
Master Permit No.
UILDING ROOFING
JOB ADDRESS: 3 G 2- A/e `j 7 57 k- F j
City: Miami Shores County: Miami Dade Zip: ?,? 1 3 Te
Folio/Parcel #: ) (- 3 2 d a-613-32-70
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): bAN.4 Ot t f_y R,owN Phone #: : 'o s - 41-0 6- q �✓6
Address: 36 2- 4/ IF 6'7 7 ; l R FF
City: 44.1 S 1-0 S State: ! L- Zip: 3 ? 1 .?
Tenant/Lessee Name: Phone #:
Email:
CONTRACTOR: Company Name: C✓ C3%_ 05s 4-2- 't s- T,t c i T S!) 4} L L 6- Phone #: ? cD S" - „� 2 s -,SL
Address: 1 1 39 1 .5-L4) 7`% 4 /��/i u
City: /t/( 4/1-1 State: 1= Zip: ?j,-,
Qualifier Name: ,7-0 z 6 ,F b Phone #: S l
State Certification or Registration #: C. &L j ,g S f 3 Certificate of Competency #:
Contact Phone #: bS 5 S 3 Email Address: ✓I i et-2 G c- / V ,, 4 1 , G G
DESIGNER: Architect/Engineer: - c� E 544JC 11 E 2- Phone #: ?C - Co 6 g -' -S.f(
Value of Work for this Permit: $ �a� 560 , 60
Square/Linear Footage of Work:
Type of Work: °Addition Olteration UNew ORepair/Replace
°Demolition
Description of Work: E PL Lao E2 1 s ti' OU b I?E 7v75 Tni T 1-1 c 134 rro
1A) `tk'O f,1 L. RF 4: A N A 71 PL- e-E Frv6 Eg jyI /416
PA- O C-O LJ I-JVS Fw.t EL_ �rTa_
******** * * * * * * ** ** * ** * * ** * * * ** * * * * * * *** Fees************* ** * * *** * * * * ** * * * * * ** *** * ** * * ***
Submittal Fee $ Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $ %1(:) ` .../.
.
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 commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
Owner or Agent
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
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.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Plans Examiner Zoning
Structural Review Clerk
(Revised 3 /12/2012XRevised 07 /10 /07XRevised 06 /10/2009)(Revised 3/15/09)
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 inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice,, the
inspec 'on will not be proved and a reinspection fee will be charged.
Signatur
Owner or Agent -IL
The f. • lomg instrument was acknowledged before me this( The forego o': ins' 4lent was ac ,..,',' , led_ aed bef. re FA
day I , : b}� 42 O ,� day of �, 2(� I� by
erson. .� , o ,� has produced ,w <o is pe onally kn to me or who has produced rif%
3�jdentification and who did take an oath.
Signature
Contractor
As identification and who did take an oath.
NOTARY PUBLIC:
Sign: G•,°�
Print:
My Commission Expires:
* * * * * * * * * * * * * * * * * * **
APPROVED BY
� tV, FLORENCE SIDER
,`` � "1; Public - State of Florida
pa Comm. Expires Oct 22, 2014
ii$0 ° Bonded Through National Wary Win.
Sign:
Print:
My Commissi
* * * * * * * * * * * * * * * **
an xanuner
Structural Review
(Revised 07 /10/07)(Revised 06 /10/2009)(Revised 3/15/09)
o�. ��•. Notary ' u
•'
4 My Comm. Expires Sep 23, 2015
c`= Commission # EE 128810
%;,o;,;-0 , Bonded Through National Notary Assn.
3 /X /2- Zoning
Clerk
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