BP-04-1626Aug. 7. 2012 10:32AM
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Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING Ri C IE II VE D , Permit No. /9 ° -/&.a63
PERMIT APPLICATION DEC 1 , ; e M .stet Permit No.
FBC 2001
ide
Permit Type (circle): Building f
/� Electrical PI mg Mechanical Roofing
Owner's Name (Fee Simple Titleholder) iii , de (J6I /cam / Phone #45) 67.49.572'7
Owner's Address i I `i5 VE /DS- 81-- •
City ni. I GI M I 51 t@ (C S State F-1—Or OA. . Zip 3.1.
Phone #
Tenant/Lessee Name
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name
Contractor's Address
City
Qualifier
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable)
Phone #
$ Value of Work For this Permit
Type of Work: DAddition ,ra + to , on DNewv
Describe Work:
❑ Demolition
** * * ******** **,t * ** *Fee * *** rat** * ***** * *** *, ** **** ***
Submittal Fee $ Permit Fee $ la f CCF $ (% , (t) CO /CC
Notary $ c------- Training/Education Fee $ (/ a 80 Technology Fee $ /
Scanning $ ------- Radon $ Zonin Bond $
Code Enforcement $
Total Fee Now Due $ ts✓ 7
(Continued on opposite side)
Structural Plan Review.
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 FT.RCTRICA,L -WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOIT,F,RS, HEATERS, TANKS and AIR CONDITIONER ET r
OWNER'S AFFIDAVIT: I certify that all the foregoing information s a te'- _ a 111 vo k will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORIU)'.bi 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.
Signature
Owner or Agent
The foregoing instrument was acknowledged before « e
day of 20 D by
who is personally known to me
eg462®0/3- - 730 entification and who did take an oath.
NOTARY P
Sign:
Print:
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 by
who is personally known to me or who has produced
as identification and who did take an oath.
lb II 514.
e:.
Commission 870
x ir 2008
es:94
B P soul Co., Atlantic $4l c. .
My Commission Expires: i My Commission Expires:
******************************************************* ******************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
Chc 05/13/03
rr
Plans Examiner
Engineer
Zoning
(-9-404Y