RC-07-112Qo Uec 26107
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Miami Shores Village JAN 2
2�0`7 a Building Department BY:
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Permit No. ( 12
Master Permit No.
Permit Type (circle): Bui ding Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Titleholder) ,04,4 e5 4 6-
aYc Phone # , O6 7e, 6 7 "c:2
Qr i o s yTr
Owner's Address
City 7fi/Irryi
5°40,-e$ State d",L
Tenant/Lessee Name
Zip
Phone #
Job Address (where the work is being d
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated YES
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Contractor's Company Name
Contractor's Address
Miami -Dade Zip
[-bit) Ow
Phone #
City
Qualifier Name
State
Zip
Phone #
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $
Square / Linear Footage Of Work:
Type of Work: ['Addition ❑Alteration ❑New ❑ Repair/Replace ['Demolition
Describe Work:
a ! rzr d - r- LO
Submittal Fee $ Permit Fee $ 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 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 41„ t . AA Y B QRg RECORDING YOUR NOTICE OF
COMMENCEMENT." �� z
Kg
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 reins. .e fee will be charged.
Signatur
4-1 41:41
Owner or Agent
Signature
Contractor
The foregoing instrument was acknowledged before me this ,97- Tfo ping instrument was acknowledged before me this
day of ja r - , 20 CO-, by 20 , by
who is erso o me or who has produced who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
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�
6cia _5
My Commission Expires: Nr a4, Z ■O
APPLICATION APPROVED BY:
(Revised 02/08/06)
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Plans Examiner
Engineer
Zoning