EL-12-901 (2)BUILDING
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
Permit No. 2-6)(0 1
PERMIT APPLICATION
FBC 20 l T
Permit Type: BUILDING ROOFING
RECEIVED
MAY 182012
Master Permit No. pc-9-11-1669
OWNER: Name II(Fee Simple Titleholder): 14 SO1 ' 14 ) Phone #:
Address: � 1 `4 1 N t I r� 2
City: 1 v \` G ,& (\O f S State: T L Zip: 3 ,_,)I3
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: 1--6L4 1 NE I O 9j S I
City: Miami Shores County:
Folio/Parcel #: 1 1 2050 I4 0
Is the Building Historically Designated: Yes
Miami Dade
zip: 33138
NO Flood Zone:
CONTRACTOR: Company Name: t-t," r0 C Ye/nAk ,TAIEhene#: (qq/
g
Address: Y s
City: % / . i
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 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
Signature
Owner or Agent
instrument was a owledge* fore -
, 20 , by , it r
y known to me or who has produced! �]I
NOT
Sign:
Print:
My Commission Expires:
As identification and who did take an oath.
PUBLIC:
41
Contractor
The foregoin instrument was acknowledged before me this 03
day of
Mil-, by ® C 2f Cll ` -14
APPROVED BY
to me or who has produced
as identification and who did take an oath.
NOTARY! t LIC:
Sign:
P
4,1t! ,,,, JOUBERI PIERRE A
e4. Notary Public - State of Florida
•� •1 My Comm. Expires Apr 30, 2018
ti o�= Commission # EE 194096
' ,° l, °PO Bonded Through National Notary Assn.
mmissior
•
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ePlans Examiner Zoning
Structural Review
(Revised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09)
Clerk