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RF-11-1938Miami 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 $'56 .o3 u,mtT- L OCT 2 0 2011 Permit No. a Master Permit No. Permit Type: BUILDING ROOFING OWNER: Name (Fee Simple Titleholder): 3 OW\ arCLO-GrO Phone #:. Addresscz t N w to 3 S+ FB 1� 3315 City: � S �G'1 �� State,: �"(, Zip: Tenant/Lessee Nam ''II __ / Phone #: Email:J( ��1l1 -'l DTl�6Dot S SC.4-6C�CS • ek JOB ADDRESS: t .I )J -U.) . l ® 2 S! City: Miami Shores Folio/Parcel #: County: Miami Dade zip: �3 l S-2) Is the Building Historically Designated: Yes CONTRACTOR: Company Address: City: State: Zip: Qualifier Name: Phone#: State Certification or Registration #: Contact Phone #: DESIGNER: Architect/Engineer: Certificate of Competency #: Value of Work for this Permit: $ 1U Type of Work: ❑Addition DAlteration Description of Work: is bra Ices - - t (e,s ©sj cROE -4 r auk., n \e . is- -h \ /pcuA4- Square/Linear Footage of Work: New epair/Replace ODemolition * * *** *x:***** ** ** **************+x****** Fees* ************** * ******** ******** ** * *** *** *** Submittal Fee $5 • Permit Fee $ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ 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, BOB .FRS, 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 IMPROVEMENTS TO YOUR PROP FINANCING, CONSULT RECORDING YOUR IN Y !; UR PAYING TWICE FOR YOU INTEND TO OBTAIN OR AN ATTORNEY BEFORE NCEMENT. " 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 Signature Contractor tru ent R_ , wledged before me this Owner or Age The foregoing instrument was acknowledged before me day of 1.° , 201 I , by 04.1■i who is personally known to me or who has produced f t a As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: APPROVED BY \ \\011 t I I I l U /00/1 C • x: 5Q.�c�� S,a;\)zi .p who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: titt'Mans Examiner Sign: Print: My Commission Expires: Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)