PT-07-998Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
BY: --- Tel: (305 795.2204 Fax: (305) 756.8972
BUILDING'] 1 (o1
PERMIT APPLICATION ev)
FBC 2004 C(LI,Cy)
Permit Type: PAINT PERMIT 01 N/tUt
7cz� �d YY1Ctrre rO
Owner's Name (Fee Simple Titleholder) (`(1l(hq�� (?eta o Phone # ('OS) -1o2Ce ` (CA 3cS
Owner's Address )LI, N •,0 `R ee-k
City IM lam 5i1Ore State Zip 33 t
Tenant/Lessee Name Phone #
E -MAIL:
Permit No.
Master Permit No.
01-9q
Job Address (where the work is being done)?( '-I o� i� l� qC( ee-e-1
City Miami Shores Village County Miami -Dade
FOLIO / PARCEL #
Zip 33 OD
Is Building Historically Designated YES NO
Contractor's Company Name CX -R.,Ir 1C
Contractor's Address
Phone #
City State Z'rj
Qualifier Name
State Certificate or Registration No.
OWNER BUILDER:
Phone #
Certificate of Competency No.
Value of Work For this Permit $ (000 , ype e#'Wotbk: ❑ Addition / ❑ Alteration / ❑New / ❑ Repair /Replace
.r,
Describe Work:
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no wf`ik 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. 1' understand that a separate permit must be secured for
ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
"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.
******** * * * * * * * * * * *** * * * * *,* * * * * * * * * * ** Fees************* * * *** * *** * * * * * * * * * * * * * * * * * * * * **
Permit Fee $ CCF $ Technology Fee:
Training /Education Fee $ Notary $ Code Enforcement $
Double Fee $ Zoning $ Total Fee Now Due $
See Reverse side -a
PAINT COLOR APPROVAL AND AGREEMENT
All elements on the site must be listed and indicate the color to be painted
Directions: Please circle corresponding number to appropriate color sample.
Walls:
3 4
Fascia: 1 Q 3 4
Drip Cap/Drip Edge:
Soffit: 1 2 3 4
Roof: 1 2 3 4
4
4
4
Chimney: 1 2 3 4
Doors and Door Jams: 1 3 4
Garage Doors: 1 A 3 4
Railings: 1 2 3 4
Fences: 1 2 3 4
Flower Bins: 1
Shutters: 1
2 3
2
3
Awnings: 1
2
3
All brick (simulated or regular): 1 2
Stucco Banding: 1 2 3
Any other Stucco Features: 1 2 3
Accessory Buildings Other:
4
Attach`colar samples withnname and
2 w1n\ 1
3
SW 6114
Bagel
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.
Signature
Owner or Agenty Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
A E31
day of 20 by .` 1�. �G 'eS3r, 4 of , 20 by
who is personally known is me or wh,(a�q{�s' 9 tSS Q®4vho is personally known to me or who has produced
As ide ificatt itk∎kahf we as identification and who did take an oath,
■itic80 NOTARY PUBLIC:
NOTARY PUBL
Sign: I_ / ign:
Print: o Print:
My Commissio Expires: My Commission Expires:
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
Plans Examiner
Preservation Board
Code Enforcement
(Revised 04/24/07)
Multitech Building Technologies, Inc.
License Number: CGC060943
License Status: Active Licenses: Cert General Contractor
Ref: 142 NW 99 ST. Miami Shores, FL.
Safety inspection
O
'42-q 553
-114EaT ED 1
AUG 2 'W
This is to certify that I have conducted an inspection at the above referenced property in order to
confirm no work was done at this property for the following trades:
Driveway Permit # BP05 -1253
Exterior paint Permit # PT07 -998
I fully understand that the City of Miami Shores Building Department will not perform any plan review or
field inspections and that the Building Official will rely solely upon this "sworn affidavit" to close out
these permits.
Signature of Qualifier 4
//
L e-ep0110 DICSpr■"
Print Name
ov)bo
State of Florida
Sworn to and subscribed before me this cZ4 day of 008'
20 VD, Y •
Signature o
Print Name
(SEAL)
rn" MELISSA RAMIREZ
!fQ*.,J�,'� \� Notary Public - State of Florida
11614 My Comm. Expires Feb 17, 2015
Commission # EE 65911
a
Personally known
Or Produced identification