RF-11-1765`i P 1
Miami 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
Permit Type: BUILDING C ROOFING
OWNER: Name (Fee Simple Titleholder): bita'dE0014- P/G Phone #:
Address: 2 10 /O
City: /r/dfii/
450.0D
c ruts_
Permit NoAFu -rp5
Master Permit No. // ' / 5 81
State:
Zip: 3 /j/
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: / 3 6 0 A' 6— /03 5 11 •
City: Miami Shores County: Miami Dade Zip: 3 3 / 3 g
Folio/Parcel #: 11 3 Z O S 0 3 0 O b '7 D
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company Name: 1111711.1 C..ervgT Q v LT 10 N Serwl c Phone#: 305- 3 Y5 —1/ 4 9
Address: 6 O65 A/ w' / 6 7 5 1. 8- a
City: P7 i 4.1►1. State: F c. o a- i b A Zip: 3 3 0 15
Qualifier Name: a-e'An 4iv b 6 / L i Phone #:0 =1) 13 Y- Y2.3 Y
State Certification or Registration #: C C G 13 Z.2061 Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:"-
Phone#:
Value of Work for this Permit: $ / . CO Square/Linear Footage of Work:
Type of Work: ❑Addition lagileration ❑New ❑Repair/Replace ❑Demolition
Description of Work:
%% M , i ice` -04-8- iIt - ' OP AlPten A2MleJ
******** ****+ x**** **** *************:x****Fees* g -.. t , 0; p * * **
CCF $ �" <- CO /CC $
DBPR $ Bond $
Technology Fee $
Submittal Fee $ Permit Fee $
/Do'
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
{� R
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 CONDmONERS, 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 COMI ENC MENT " r ` '
2 x• s r
Notice to Applicant: As a condition to the issuance of a building permit with kn esttiiteatea vau`e`e cWting 425 &J 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
inspegdi .will n9t b�.appr ved and a reinsgection4eewill be char d.
- �. rii} �t ��b�s., �e►s r.t�i 4.,A0._ Sr�H
•
Signature
The , ,:omg
day of IA
w +oispe :.
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,Signature
f, e! r a
instrument was ac w dged befo : e this I J The eg g.i tru e;9 , . wledged ."efore me this 15
/I to >
20 11 , b • la a 1'ILi4R1 V4 day of 5 FP , 201f , by E Gt tI c I
own to me or who has produced / }rho is personally known to me or who has produc
As identification and w o did take an oath. as identification and who did take an oath.
BLIC: . ' '' NOTARY PUBLIC:
ti I L AA// 16 Sign:
Sign:
Print:
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My Commission Expires:
Guam NI60.1
., Notarl 44 . State F 14
4. pass Sep 2a 2016
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Print:
My Commissio
PAS M Sonde
Commission My C� May.02, 208
APPROVED BY
Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487 -1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399 -0783
DE GIULI, GERMAN
2005515RE COUNTRY CLUB DRIVE #447
UNIT #508
AVENTURA FL 33180
Congratulations! With this license you became one of the nearly one million
Floridians licensed by the Department of Business and Professional Regulation.
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Every day we work to improve the way we do business in order to serve you better.
For information about our services, please log onto www.myfloridalicense.com.
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constantly strive to serve you better so that you can serve your customers.
Thank you for doing business in Florida, and congratulations on your new license!
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