BP-05-959Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building Ele
Owner's Name (Fee Simple Titleholder)
Owner's Address / ` `21,
City /(94/41/4).719,?:" State rl_
Tenant/Lessee Name
Permit No. EP06 q5C/
Master Permit No.
Plumbing Mechanical Roofing
Phone # '_ • '
Zip
Phone # ' L
Job Address (where the work is being done) r
City Miami Shores Village County Miami:Dade Zip
NO fr"
Is Building Historically Designated YES
Contractor's Company Name
Contractor's Address °")(24,%7 '+,/ ` '
City
Qualifier e,
State Zip
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit
Type of Work: ❑Addition
Describe Work: 7/4 f
49?
❑Alteration
❑New
Phone #
Square Footage Of Work:
ti Ley-r-
Repair/Replace ❑ Demolition
e , Jo /07_
* * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ SO . 00 ` Permit Fee $ l 00 CCF $ I ' ' CO /CC
Training/Education Notary $ (, Technology Fee $ eir_.---.: 2 !__
Zoning Bond $
Scanning $ ~
Radon $
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $
(Continued on opposite side)
c
V-,`C. L:x,
AT
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.
Signatur
Owner or Agent
The foregoing instrument was acknowledged before me thish,
day ofi.J /f 0 , 20(1-› , by
who is personally known to me or who has produced.:
c/ f;:t As identification 4nd who did take an oath.
NOTARY P �3LIC:
Sign:
Print:
My Commission E
/L.
* * * * * * * * * * * * * * * **
111
ti
LOR IN
Public - State of Florida
4 My Commdsion Ex** A r
Commission 1 DO 109725
W PV Bonded By Rational Notary Assn.
Signaturb_
Contractor
The forgoing instrument was acknowledged before me this/0
day of .Uf. , 204 by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commis
* * * * * * * * * * * * * * * * * * * **
Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
*w� Note _ u. ` a r,*Y
I: My Commission Ex. y: -x Apr 16,2006
m
**
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1 a�
APPLICATION APPROVED BY:
Chc 12/15/03
Plans Examiner
Engineer
Zoning