PL-07-1961 (2)Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATIO
FBC 2004
CE
SEP 1 8 2007
BY
Permit No.
t'itt1
Master Permit No.
Permit Type (circle): Building Et a
1 °' ' � N � T%� Mechanical Roofing
mss
Owner's Name (Fee Simple Titleholder) lQ_ t GQm tctra.. Phone # 954 SW-- -7 4.e' S g-"
Owner's Address RI- 8. /\31C-- P 3 ii- SI-
City (Y)NQ YY11 State
Tenant/Lessee Name
Job Address (where the work is being done)
City Miami Shores Vill. e County
FOLIO / PARCEL # I
Zip 3 3
Phon
Is Building Historically Designated$ YES
Contractor's Company Name r
Contrac ' Address
City latft.ik,
Qualifier Name r
State Certificate or Registration No.
Architect/Engineer's Name (if applicable)
State
P,(6-rM,
Zip 55
Phone # ar)-5 65-1
Zip
Phone # 1&
Certificate of Competency No.
Phone #
Value of Work For this Permit $ �a��. Square / Linear Footage Of Work:
Type of Work: []Addition
❑Alteration
Describe Work: °'
i t O
['New
epair/Replace
0 Demolition
* *, * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * *Fees7** ******* * * * * * * * * * * * * * * * * * * * * * * * * * * * ** **
Submittal Fee $ Permit Fee $ )1 CCF $ CO/CC
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $
Total Fee Now Due $
See Reverse side -->
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
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 afte permit is issued In the abtence of such posted notice, the
inspection will not be approved and a r
Owner or Agent
The foregoing instrument was acknowledged before me this I'1 The foregoin• instrument was acknowledged before me this (%
day of
day of ; by I k,tyi c d
'W 2I:. by
who isjersonally known to me or who has produced who iozpeLamally.=.1molun..M..= or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print
My Commissio
* * * * * * * * * * * **
'Q MY COMMISSION # DD4719o3
pa EXPIRES: Sept. 14.2009
APPLICATION APPROVED BY:
(Revised 02/08106)
* * * * * * * * * * * * * *-
� jLq, - �L � L � �' � `/ 9�Plans Examiner
Engineer
Zoning
Sign:
Print
My Comm
* * * * * * * **
MY COMMISSION # DD471903
si as i es: EXPIRES: Sept. 14, 2009