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WS-12-1057Miami Shores Village $ `� 0. Buildin g Department De 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 6 w . Tel: (305) 795.2204 Fax: (305) 756.8972 r, SPECTION'S PHONE NUMBER: (305) 762.4949 1 verb- BUILDING ►1 Permit No. M 1M-1 PERMIT APPLICATION Master Permit No. Permit Type: BUILDING ROOFING JOB ADDRESS: 10 G•r ld c+ City: Miami Shores County: Miami Dade Zip: 33 I Folio/Parcel#: 11-- ZZ31 --Ci Is the Building Historically. Designated: Yes NO V Flood Zone: OWNER: Name (Fee Simple Titleholder): r 4Q L ` jr Phone#: 3,05415-2.515 Address: ICS& S J i 2, + City: Yet A W U. 3 '4 f. -Y e.3 State: Tenant/Lessee Name: Email: Phone#: ( 9 ) 4 36 —6,9443 Qnalifter Name: (j [ .s L 1 Phone#:e4476 i "in - O cf tic/ State Certification or Registration #: Certificate of Competency #: Contact Phone#: 3') y'i . o DESIGNER: Are hYtect/En ' : guteer Value of Work far this Permit: $ M©," / Square/Linear Footage of Work: Type of Work: DAddition DAtteration UNew tRepair/Repiace Description of Work: ODemolition Color thru tile: * ap e a Submittal Fee $ Permit Fee $ /70 61° CCF $ CO/CC $ Radon Fee $ DBPR $ Bond $ Training/Education Fee $ Technology Fee $ Scanning Fee $ Notary $ 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 indicate& f 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 COMMENCEMENT IMPROVEMENTS TO '15' FINANCING, CONSULT RECORDING YOUR NOTICE OF C YOUR FAILURE TO RECORD A NOTICE OF SULT IN YOUR PAYING TWICE FOR PERTY. IF YOU INTEND TO OBTAIN LENDER OR AN ATTORNEY BEFORE NT." Notice to Applicant: As a condo' ion to the issuance of a building pe k estimated value exceeding .$2500, the applicant must ....1.: promise in good faith that a copy of the notice of commencement and co n lien law brochure will be delivered to the person whose property is subject to attaclunent. 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 t be approved and a reinspection fee will be charged. Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this 14.14. The foregoing instrument was acknowledged before the this day of _ lJflt.,20 _12..by , day of ' , 20 by who is personally known to $ 1 , 1, who has produced As ide . i'.' rt. „!'on lid who did take an oath. NOTARY PUBLIC: NOTARY PM° My C STATE OF FLORIDA - Commit EE000730 who is personally known to rat or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: 0 *IFXRIEGISSMINgett************************** Structural Review (Revised 3/12/2012XRevised 07/10/07)(Revised 06/10/2009)(Revised 3/15109) ARY pusuc STATE OF FLORIDA Commit EE000730 EaPireeeteMoyr************ Zoning Clerk