BP-05-1228Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305 7 2204 'ar, ( 72
1
BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): ( Building Electrical
Permit No. ` QS— 12 ?-8 _
er Permit No.
Avkla
Plumbing Mechanical Roofing
Owner's Name ( Fee Simple Titleholder ) Ni Phone # -
5 � q (; ) (&"''
Owner's Address
City H! 44/4"41 .` 5 State
Tenant/Lessee Name
Job Address (where the work is being done)
City Miami Shores Villa e County Miami -Dade Zip ?j3 L
Is Building Historically Designated YES NO
UCH
Zip -"?j °7) 3
Ph e#
Contractor's Company Name CL) ( . i.k. .TI 114
J ) Li
City rt i State
Contractor's Address
Qualifier t .� C:' tL- � t: C? t
State Certificate or Registration No. (-
Architect /Engineer's Name (if applicable)
$ Value of Work For this Permit
Type of Work:
Describe Work:
Addition
t12
C"�
Phone # 30S
Zip t
Certificate of Competency No.
Phone #
Square Footage Of Work:
tion fNew Repair/Replace ❑ Demolition
A, "5 C4-1 k-4 .tx-71-)
* * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ CCF $ CO /CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ Zoning Bond $
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $
(Continued on opposite side)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
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 ins
commenced prior to the issuance of a permit and that all work wil
construction in this jurisdiction. I understand that a separate perm' mus
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS
Zip
lati s indicated. I certify that no work or installation has
e j•erformed to meet the standards of all laws regulating
ecured for ELECTRICAL WORK, PLUMBING, SIGNS,
CONDITIONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing in f, > is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
e
"WARNING TO OWNER: YOUR FAILURE TO ' r .. I RD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS 0 UR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER 1' ' N ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT."
Notice to Applicant: As a condition,' o the is ^; e of a buiM'ing permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy o he noti e of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachme Al , a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs s. (7) days after the building permit is issued. In the ab _,'nce of such posted notice, the
inspection will not be apprgved an a r' inspection fee will be charged.
Owner or Agent
The foregoing instrument was acknowle ged before me this 1
day off l V 0 (:)by V (Ls/ 1 l 1 ,
who is person wn to me or who has produced ,
As identification and who did take an oath.
NOTARY
Sign:
Print:
My Co mission Expires:
* * * * * * * * * * * * * * * * * * * * * **
fiTmc
* * * * * * * * * * * * * * * **
Ting C
Signature
The foregoing instrument
day of
who is personally kn
NOTARY PU'BLI
Sign:
Print:
My +m «ission EigOir
, 20
Contractor
s acknowledged befor
)•y vie
me this 1 4E5
• `,e-C4C,rl.
me or . o .: s produced
tificati e . who did take an oath.
A11001.6-
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
**.k***+ ********* k**************** *+ k**************#********** ******* ***************
APPLICATION APPROVED BY:
Chc 05/13/03
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* * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
Engineer
Zoning