RC-12-34 (2)411 P
Miami 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
Permit Type: BUILDING
CEI V :.
AUG 292012
FBC 20 ICS
Permit No. ge"
Master Permit No.
ROOFING
JOB ADDRESS: /5-'7' "1"' / //s f" �y
City: Miami Shores County: Miami Dade Zip: 33 /G d
Folio/Parcel #:
Is the Building Historically Designated: Yes NO 1,- Flood Zone:
OWNER: Name (Fee Simple Titleholder): 07a hi 0 V. 2j i e 2- Phone #: t V2- -6 3l d 65-cf
Address: 1 S-4 A W.. ill SP
City: r a.wl i S leiDre State: F( Zip: 3 91 &?
Tenant/Lessee Name:
Phone #:
Email: l S F c e C P e 1 "1, L l 1..5 c,0 E 6 uvi_ K
0 1.6 14.4
CONTRACTOR: Company Name: One COPZS1%UC1'OP1 Phone #: `/ g 6'" 29,- % ZP 9
Address: 4 2 1 T S, W, 2 • 7 v'r
3
City: ✓�idr�n l State: r L-- Zip: 3 sei
Qualifier Name: S, tiS VV 1 e( Z �j uez Phone #: �%.0 6 299 '92e9
State Certification or Registration #: 2 ( C `So fYZ 0/? Certificate of Competency #:
Contact Phone #: r/86 — 299-7 Z e q Email Address: 0 CS Gl s l� at p ne ci-4P c o n s Tfatl , do,71
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: LlAddition ❑Alteration �ONew ❑Repair/Replace ❑Demolition
Description of Work: ? UJQ) 0 Ai
Color thru tile:
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ 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, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: 1 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 po ted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In a absence of suc posted notice, the
inspection will no e approved and a reinspection fee will be charged.
Ott
Owner or Agent
Signature
Contractor
The forgoing instrument was acknowledged before me this "�°j ' The for `pgoing instrument was acknowledges) before -this �j�b
day of A vl , 2012 , by ia� Go I..�_, day of A % , 20 I2 , by • ei∎is
who is personally known to me or who has produced s '"L DI.1 y'who is personally known to is - or who produced
As identification and who did take an oath. as i n� catio who did take an oath.
NOTARY
My Commission Expires:
40 �P% HENRYGONTALEZ
* MY COMMISvSION I EE 221657
® EXPIRES: August 9, 2016
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My Commission Expire
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* MYCOMMISSI0N #EE221657
EXPIRES: August 9-, 2016
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APPROVED BY
Plans Examiner
Structural Review
(Revised 5 /2/2012XRevised 3/12/2012) )(Revised 06 /10 /2009XRevised 3 /15 /09)(Revised 7/10/2007)
Zoning
Clerk
•
.Ur1/v a
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. IC " /-61
Owners Name (Fee Simple Title Holder): l clvvi go v►, Z `e° Z Phone #: /?°7 —63/ "c _rf
Owner's Address: t ✓v, W, l ! / 5 Y-
City: ✓lj a cs,. SGloVeC State : F 1-- Zip Code: 3 3 t 6-e
Job Address (Of where work is being done): /5-11 /1"/4*(J /7" s 14
City: Miami Shores State: Florida Zip Code: 1 1 G
Contractor's Company Name: Oh e .c7"-Of I1 to /t c-/-7V i1 Phone #: 765-- 442 -299
Address: c „W,, z 7 rv'
City: , I`etw i P State: FL- Zip Code: If LS
Qualifier's Name : f sIt's tie fir zt tie ? Lic. Number: C �c /se sz08
Architect/ Engineer of Record Name: Phone #:
Address:
City: State: Zip Code:
Describe Work: U Locf 0,k
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 Buildin • fficial an • the
Mia Shores harmless for all legal involvem
Signature
Signature
owner or Agent ✓ ontractor or Architect
The foregoing in trument was aknowledged before me The foregoing ' trument was aknowledged before me
this day of 2017,by l-ic►e•i GYAZ 1C.:1—
Who is personally known to me or who has produced
rt._ v4 i ' Li _ as indentification.
this 2-1 day of
, 20 byligi 1Q044v41
who is personally known to me or who has produced
.. 2.1otr”' 'C
as indentification.
Notary P 7 . Notary Publ'
Sign: !` ` Sign:
Seal: �.. 4e4c; " "!� GONZAL.EZ Seal: *o PBU
• MY COMMISSION # EE 221657 14:NRYG ZALEZ
* ��' * * � , �* MY COMMISSION 9 EE 221657
mr, EXPIRES: August 9, 2016 ,� < EXPIRES: August 9, 2016
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