RF-11-1295Miami 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
FBC 20
Permit Type: BUILDING PROOFING
OWNER: Name (Fee Simple Titleholder): 6TF'.t►
Address: Z'1 N Li 1 b S S'} •
City: M 1 A 144 15 NO 12-E
Permit No.
S f ��t
JIJL 1 9 2011
Master Permit No.
Phone #: RS" 751- 3.662
Tenant/Lessee Name: r�
Email: gR1TTC2seaYAkQe51 `c.OV'4
Phone #:
Zip: 33tSO
JOB ADDRESS: zq N'' 16 S 3#ree t
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #: ///' 0/36— 0005. 03 ®®
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company Name: CO/) A /ZOO F1(ij 1 Z, . Phone #: 30S" 6 t' I D (o 0
Address: 11 (.9 7€ E 10111 [A(V C •
City: f/ i /Eft State: Ti DiR 111A
Qualifier Name: 1 i4 guc(a A IV 3
State Certification or Registration #: CCL / 32. 6 095— - Certificate of Competency #:
zip: 33013
Phone#: 786-367-6 tti 7
Contact Phone #: 3'0 (U $1-1 Gad Email Address: COD A IZO®f a Gel
DESIGNER: Architect/Engineer:
value. of Work for this Permit: $ 4 V a 0 16° Squar
• Type of Work:, DAddition t OAlteration
of Work:
epairlReplace
ODemolition
Description of Work: /'f E Air 6 S" pm, , t +J MA I� F Sy S0 IA C t� lidl �y (Ii�/ B 1 C1 <'
\
/, r . Ail etA4 t1 U c '! ( , i "� bA( .., j P14 -1'& s gd+ew E
Akin. P'i . 9 A 1 411 69S- peect(it1t&.. .Ct
kack
***** *m ***** *x:**** ** *******m*********** Fees**** * *** ****+x** ** : ****** ********s:**+x ****+x***
Submittal Fee $ Permit Fee $ /c70 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 t1}e,w`d \and) tjsta1lations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and th t.41 'wer1C will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understan Safi �a,1s�Re permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, A />AI S, 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 #'inspection fee will be charged.
Signature
Owner or Agent pp��
The foregoing instrument was acknowledged before me this C�
day of at y , 20 by, v'en r
who is personally known to me or who has produced flc in c
As identification and who did take an oath,
NOTARY PUBLIC:
Sign
Print:
My Commission Expires:
Signature
Contractor
The foregoing instrument was u acknowledged before L
�fore me this f
day of 3.1.,t , 201 \ , by Of I«Vtcxl0 Lo o n ® ,
who is; persona y known to me or who has produced perc,no .t.5
\41tIt'Ars■ ' A r -as identification and who did take an oath.
NOTARY PUBLIC:
* * * * * * * * * * * * * * * * * * * * * * * * **
APPROVED BY
************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Zoning
Clerk