FW-11-1200 (2)Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Mi mi Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
cr
RE CP
AUG 292012
FBC 2010
BUILDING Permit No. f 7 I/- ®O
PERMIT APPLICATION Master Permit No.
Permit Type: BUILDING ROOFING
JOB ADDRESS: /CY 4J ' `775
City: Miami Shores County: Miami Dade Zip:
'3 -5/'8d
Folio/Parcel #:
Is the Building Historically Designated: Yes NO 1,../-- Flood Zone:
OWNER: Name (Fee Simple Titleholder): 3 1 s . C y �6vi �. Phone #: 7qz 3 i
Address: i 5-4 V • vV l (1 St.
City: ` roil a C cre< State: Pt— Zip: 3 91 a
Tenant/Lessee Name: l Phone #:
Email: l �'f c' �.► a e C e Qcx 1 vl I I tic (� C'0 Q cJ'- 'uJ . i L , CEO vvl
r
CONTRACTOR: Company Name: Oh e SfOj 0 n$ 7cm fto1i Phone #: 96 - 2 9 9 -1 209
Address: .S
I/ 2, (4 , V % 2 e t
Ir
City: ../44 1 et. WI I / State: Ft- Zip: 3 3/ 3 c�
Qualifier Name: (7 ti .s VGfq z Get° Z Phone #: 0/ -' 299 1/2�!
State Certification or Registration #: a ch a 1 56 S2. Og Certificate of Competency #: l
Contact Phone #: tS 6' - 2 %q — 7 2 01 Email Address: i T ''$ U[ !e 0 t e City CO h -S �' NC //Oh d 60119
Phone #:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑Addition DAlteration ,� 1 ONeew DRepair/Replace DDemolition
DescriptIaa -of Wt rk: - C3k CM
tY - 0) a ..
Color thru tile:
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** **** Fees*** * * * * * * * * * * * * * * * * * * * * * * *4 * * * * * ** * * * ** * * **
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
03
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
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, 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be s osted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of : ch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature L✓/,eu�, Signature
Owner or A e nt / Contractor
The foregoing instrument was acknowledged before me thisai The foregoing instrument was acknowle
day of .4uCrSA' , 2012 , by Trg%PA Georszsi k,. , day of lV tie)A- , 2011— , by
who is personally known to me or who has produced VebilAJf;Cwho is personally known to me or who has produced ' L.
As identification and who did take an oath.
Sign: W
Print: 114 �e..�
My Commission Expires: * , ; *EXPIRE$:Aug uEE221657
EXPIRES: August 8, 2016
4,to o •O wed That Bulge *day Services
1_/ C as identification and who did take an oath.
NOTARY PUB
Sign:
Print:
My Commission Expires:
mac* MYCOMMISSION657
EXPIRES: August 9, 2016
Banded Ttau Budget Notary Send
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPROVED BY
Plans Examiner
Structural Review
(Revised 5 /2 /2012)(Revised 3/12/2012) )(Revised 06 /10 /2009XRevised 3 /15 /09)(Revised 7/10/2007)
Zoning
Clerk
Miami Shores Viiiage
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR/ARCHITECT
Permit N. iti- 7 f(- I x®
Owner's Name (Fee Simple Title Holder): 0 i�t G 24 6 er, Phone #: 170'2- -‘3 / —6.6 S
Owner's Address: 1 .S—'f Rev A i i/ . 1 I 1
City: .A4 c"ou41 i _S- c, v- e S State : P L_ Zip Code3 / 6./P
Job Address (Of where work is being done): /c 4/" 1/1 s t
City: Miami Shores
State: Florida
Zip Code: 3 3 f 6 g'
Contractor's Company Name: CO e Ci1C(7oi Phone #: 30 5-- 4f2- 2 % %,
Address: q 2 ! S, 2. Tev '
City: ../14 ?a frn State: E L_ Zip Code: 3 ?! 3q
Lic. Number: 0.6C LSo 5709$
Qualifier's Name : Dec c t Ve [q 2? we?
Architect/ Engineer of Record Name: Phone #:
Address:
City: State: Zip Code:
Describe Work: Few
I hereby certify that the work has been abandoned and /or the contractor/architect is
unable or unwilling to complete the contract. I hold the Buil .' • Official a the
Miami Shores harmless for all legal invo - nt.
Signature
owner or Agent
The foregoing in ment was aknowledged before me
this day of ,20Y2,by' ,atM
Who is personally known to me or who has produced
r L '�itri ' " C as indentification.
Nota
Sign:
Seal:
44,* MYCOMMISSION EE 221657
EXPIRES: August 9, 2016
BotaledItvu Budget Nay SetWees
Contractor or Architect
The for ping instrum : t was aknowledged
this DA) day of
20?
who is personally known to m or who has produced
as indentification.
Notary Public
Sign: .r
Seal:
e °` •.• '. GONZALEZ
* MYCOMMISSION! EE 221657
,_ EXPIRES: August 9, 2016
44.0Frti :I ave Budget Noisy